A Chronic Problem

By January W. Payne
Washington Post Staff Writer
Tuesday, March 6, 2007

New guidelines released last week by the American Heart Association, advising doctors to withhold medications to treat chronic pain until other treatment options have been exhausted, have left some patients frustrated and confused, wondering what's safe to take for pain, experts say.

The statement, published in the journal Circulation, suggested that doctors urge patients to try exercise, orthotics, weight loss, physical therapy and hot or cold packs before turning to medication, especially nonsteroidal anti-inflammatory drugs, or NSAIDs (such as naproxen and ibuprofen), and COX-2 inhibitors (Celebrex) to treat chronic pain. The new guidelines follow several years of debate about the value, and potential danger, of such medications.

Wondering how the new recommendations apply to you? We answer some questions below.

Just a few years ago, experts called Vioxx a wonder drug. Now, not only is it gone, but we're being warned off other painkillers, too. Why can't the experts get it right?

This backing off isn't totally new. It is the culmination of evidence that has been accumulating for some time, linking extended use of NSAIDs -- available both by prescription and over the counter -- to increased risk of heart disease. The guidelines simply formalize advice that your doctor probably already had.

I've been taking a prescription NSAID regularly for arthritis. Does this mean I should stop?

Not necessarily. But you'll want to discuss options with your doctor.

Several studies published since 2000 have noted increased risk of heart attack and stroke from NSAIDs and COX-2 inhibitors, so it's likely your doctor is aware of the risks.

The only remaining COX-2 drug on the market is Celebrex; the two other drugs in this class, Vioxx and Bextra, were withdrawn from sale in the United States in 2004 and 2005, respectively.

Research shows that if 100 patients who are at risk for heart disease or have had heart attacks take COX-2 inhibitors for a year, six additional deaths would be expected, the AHA report states.

NSAIDs can also cause stomach bleeding and ulcers, making them unsuitable for some patients. This risk can be decreased by taking proton pump inhibitors (stomach-protecting medications) to protect the gastrointestinal tract.

If I stop taking NSAIDs, what other pain relief options do I have?

The AHA statement suggests that after other non-drug measures have been exhausted, people should try acetaminophen (Tylenol); tramadol (Ultram), a prescription analgesic; and prescription opioids (narcotic analgesics) first, followed by NSAIDs. COX-2 inhibitors should be used a last resort. Opioids are often used for short-term, acute pain but are typically used sparingly for longer-term pain because of their potential for addiction and physical dependence.

Contact your medical provider to discuss your concerns, advises Marc Hochberg, professor of medicine and head of the division of rheumatology and clinical immunology at the University of Maryland School of Medicine. (Hochberg has worked as a paid consultant for several drug companies, including Bayer, Novartis and Merck.)

I'm considered at risk for heart disease but still take an NSAID for chronic pain. What do the new guidelines mean for me?

"If you have a risk for heart disease, make sure that your risk factors are being managed" -- that is, that you're taking aspirin, if needed, as well as blood pressure drugs or other medications to lower your risk for heart attack or stroke, Hochberg advised. You should also "discuss why you're taking [a] nonsteroidal anti-inflammatory" medication with your doctor. Consider acetaminophen or other non-NSAID pain medications like tramadol, as well as topical or injectable agents, he said. Be aware that each treatment carries its own risks, so discuss the benefits and drawbacks with your doctor.

How likely are other measures, such as physical therapy or antidepressants, to help me manage my pain?

That depends on the cause and severity of your pain. Physical therapy and exercise -- which "relieves tension, increases flexibility, strengthens muscles and reduces fatigue" -- can ease chronic pain, too, by helping "you regain strength, energy and a more positive outlook on life," according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases. "Because exercise raises the body's level of endorphins -- or natural painkillers produced by the brain -- it will relieve pain somewhat."

For some people, certain antidepressants, including Paxil, Zoloft, Elavil and Tofranil, may be effective. Other options include topical pain relief patches, sprays, lotions and creams such as Bengay and Aspercreme. Corticosteroids may also be useful in relieving pain caused by inflammation. Patients should note that all treatments carry their own risk of side effects, which should be weighed against the benefits of that particular therapy.

What if I've already tried physical therapy and other non-drug methods of treating my pain? Will my doctor refuse to continue prescribing NSAIDs (such as Mobic and Orudis) for me?

If you're at low risk for heart attack or stroke, your doctor will likely advise you to continue to take NSAIDs, Hochberg said.

I don't have heart disease, but a close relative does. Does that mean I can't take an NSAID?

It might. In evaluating if it's safe for you to take an NSAID, your doctor may consider your family history as well as your own medical history and risk factors for heart disease, experts say.

Is taking aspirin safe?

Aspirin is considered an NSAID, but it "does not increase the chance of a heart attack," according to the Food and Drug Administration. In fact, your doctor may suggest you take aspirin daily to prevent cardiovascular problems. It does, however, pose a risk of stomach bleeding, like other NSAIDs.

Are there any online resources I can consult?

Yes. Here's a short list:

FDA primer on NSAIDs: http://www.fda.gov/cder/Offices/ODS/MG/lansoprazoleMG.pdf.

Cleveland Clinic's Guide to Pain Medicines: http://www.clevelandclinic.org; search for "pain medicines."

American College of Gastroenterology: http://www.acg.gi.org/patients/women/asprin.asp.

American Academy of Family Physicians Guide to NSAIDs: http://familydoctor.org/802.xml. ยท

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