Medication Management

Overview

There are multiple over-the-counter (non-prescription) and prescription medications that can be helpful in relieving pain and addressing related symptoms while an episode of back pain is getting better. Careful attention to pain management is a critical component of a patient’s recovery, as acute or chronic low back pain can lead to depression, difficulty sleeping, and difficulty exercising and stretching, all of which in turn can exacerbate and prolong a painful back condition.Pain relievers are generally available in three forms: oral, topical, and injection.

  • Oral pain medications. There are many forms of pain medications that are taken by mouth – pill or liquid form – and they each work differently and have unique benefits and potential risks. Some are available only by prescription.
  • Topical pain medications. These products are applied to the skin and are intended to reduce localized pain, such as pain from a sore muscle or from an arthritic joint. Most are available without a prescription. Brands of several popular topical pain relievers include Icy Hot, Arthricare, Zostrix (capsaicin), Aspercreme, Ben Gay, and many store brands.
  • Injections. Pain relieving medication and/or anti-inflammatory medications can be injected directly to the source of the pain.
  • For more information on injections, see Injections

 

This article focuses on oral pain relievers and the most common categories of medications used for lower back pain and neck pain.

Nonprescription Pain Medications

Nonprescription Pain Medications

While there are many over-the-counter pain medications used to address back pain, the two most common types are acetaminophen (for example, brand name Tylenol) and non-steroidal anti-inflammatory drugs or NSAIDs (for example, brand name Advil). Because acetaminophen and NSAID’s work differently to address the pain, they may be taken at the same time. For example, a patient in severe pain may take the recommended dose of acetaminophen, and then two to three hours later take the recommended dose of ibuprofen, and repeat this pattern as appropriate.

Prescription Pain Medications

Prescription Pain Medications

For short periods of time, prescription medications (such as narcotic pain medications or muscle relaxants) may be helpful to alleviate pain or related complications. Other classes of drugs (such as antidepressants or anti-seizure medications) can also help modulate the sensation of pain and can be taken on a prolonged basis.

There are risks, side effects and drug interactions with any medication, so a medical professional should always be consulted prior to taking medications. Patients should be especially cautious with medications if they are on other medications or have any significant medical conditions (e.g. diabetes).

While a few major risks and side effects are outlined for some medications on this site, patients should always read the label and package inserts and consult with a physician for a complete understanding of risks, side effects, and drug interactions.

This article provides a thorough overview of the most common prescription and nonprescription medications used to relieve back pain and neck pain.

Acetaminophen is probably the single most effective non-prescription medication for lower back pain and neck pain and generally has the fewest side effects.Tylenol is an example of a well-known brand name medication that has acetaminophen as its active ingredient, and most pharmacies sell generic versions of acetaminophen as well.

Unlike aspirin and non-steroidal anti-inflammatory drugs, acetaminophen does not have an anti-inflammatory effect. Instead, it relieves pain by working centrally (in the brain) to switch off the perception of pain. Up to 1,000 mg of acetaminophen may be taken every four hours, up to a total of 4,000 mg within 24 hours.

Potential Benefits of Acetaminophen

Potential Benefits of Acetaminophen

In addition to its efficacy, acetaminophen is frequently recommended because it has few side effects. Notably:

  • There is no chance of addiction with acetaminophen
  • Patients do not develop a tolerance (loss of pain relieving effect) with extended use of the medication
  • It does not produce gastrointestinal (stomach) upset
  • Very few patients are allergic to acetaminophen

Overview of Potential Risks of Acetaminophen

Overview of Potential Risks of Acetaminophen

Importantly, acetaminophen is cleared through the liver so patients with liver disease should first check with their physician.

Patients should never take more than 1,000 mg every four hours (the maximum recommended dosage), as higher doses provide no additional pain relief and can harm the liver.

As with any medication, patients should read the acetaminophen package insert and note the potential risks and comply all of the instructions.

For severe episodes of low back pain or neck pain, narcotic pain medications (also referred to as opioids) may be prescribed. Clearly, narcotic agents are strong and potentially addictive forms of medication and should only be administered by a physician.

All narcotic agents have a dissociative effect that helps patients manage pain. It does not actually deaden the pain, but works to dissociate patients from the pain. Commonly used narcotics, listed in ascending order of potency (strength) include:

  • Codeine (e.g. Tylenol #3)
  • Hydrocodone (e.g. Vicodin)
  • Oxycodone (e.g. Percocet, Oxycontin)

In general, narcotic medications can be highly effective in treating back pain for short periods of time (less than two weeks). After the initial two weeks, the body rapidly builds a natural tolerance to narcotic medications and they lose their effectiveness. While some physicians believe that narcotics can be used long-term at low doses to treat chronic pain, narcotics are most commonly used to treat severe acute (short-term) low back pain or post-operative pain.

Muscle relaxants are not really a class of drugs, but rather a group of different drugs that each has an overall sedative effect on the body. These drugs do not act directly on the muscles; rather they act centrally (in the brain) and are more of a total body relaxant.

Typically, muscle relaxants are prescribed early in a course of back pain, on a short-term basis, to relieve low back pain associated with muscle spasms. There are several types of muscle relaxant medications that are commonly used to treat low back pain.

Muscle Relaxant Medications List

Muscle Relaxant Medications List

  • Carisoprodol (Soma). This drug’s dosage is 350mg every eight hours as needed for muscle spasm. Soma is typically prescribed on a short-term basis and may be habit-forming, especially if used in conjunction with alcohol or other drugs that have a sedative effect.
  • Cyclobenzaprine (Flexeril). This medication can be used on a longer-term basis and actually has a chemical structure related to some antidepressant medications, although it is not an antidepressant. Usually it is prescribed as 10mg every six hours as needed to relieve low back pain associated with muscle spasm, or it can also be prescribed as 10mg at night as needed to help with difficulty sleeping. Flexeril can impair mental and physical function, and may lead to urinary retention in males with large prostates.
  • Diazepam (Valium). Valium is usually limited to one to two weeks of use, and the typical dosage is 5-10mg every six hours as needed to relieve low back pain associated with muscle spasm. Because of its habit-forming potential, and because it changes sleep cycles and makes it very difficult to sleep after stopping the drug, Valium should not be used long term. Patients should also note that Valium is a depressant and can worsen depression associated with chronic pain.

Oral steroids, a non-narcotic type of prescription medication, are very powerful anti-inflammatory medications that are sometimes an effective treatment for low back pain. Like narcotics agents, oral steroids are intended for use for short periods of time (one to two weeks). Oral steroids come in many forms, but are usually ordered as a Medrol Dose Pack in which patients starts with a high dose for initial low back pain relief and then taper down to a lower dose over five or six days.

When used on a short-term basis, there are generally few complications associated with oral steroids. There are, however, a number of potential complications associated with long-term usage of oral steroids. Adverse side effects can include weight gain, stomach ulcers, osteoporosis, collapse of the hip joint, as well as other complications.

It is important to note that diabetics should not use oral steroids since the medication increases blood sugar. Steroids should also not be taken by patients with an active infection (e.g. sinus infection, urinary tract infection) because they can make the infection worse.

Ultram is a type of narcotic-like oral pain reliever that is often prescribed to treat lower back pain, neck pain, sciatica, and related conditions. Ultram, also known as tramadol, was approved by the FDA in 1998 and acts centrally (in the brain) to modulate the sensation of pain.

It is not an NSAID (nonsteroidal anti-inflammatory drug) nor does it have the anti-inflammatory effect of an NSAID. Its mechanism of action is similar to acetaminophen (e.g. Tylenol), but Ultram is a stronger pain reliever than acetaminophen and has a weak narcotic effect.

While Ultram is technically a narcotic or opioid pain medication, it is different from typical narcotics in that patients do not build up a tolerance with extended usage and there is a very low incidence of addiction. With other narcotics there is a general tendency to escalate the dosage of the medicine with time and a chance of addiction. The narcotic effect of Ultram is not as strong as the narcotic agents in other common pain medications, such as Vicodin (hydrocodone) and Oxycontin and Percocet (Oxycodone).

Because most episodes of back pain have inflammation as a contributing factor, anti-inflammatory medication such as non-steroidal anti-inflammatory drugs (NSAIDs) is often an effective pain medication treatment option.

The types of NSAIDs reviewed on this page work like aspirin by limiting the formation of inflammation, but have fewer gastrointestinal side effects (such as gastritis or ulcers) than aspirin.

Most Common Types of NSAIDs

Most Common Types of NSAIDs

NSAIDs comprise a large class of drugs with many different options. In addition to aspirin, there are currently several types of both non-prescription (over-the-counter) NSAIDs and prescription brands of NSAIDs. The three types of NSAIDs most commonly used to treat many types of back pain and neck pain include:

  • Ibuprofen (e.g. brand names Advil, Motrin, Nuprin)
  • Naproxen (e.g. brand names Aleve, Naprosyn)
  • COX-2 inhibitors (e.g. brand name Celebrex)

The type of NSAID recommended will usually depend on a number of factors, including the patient’s diagnosis, clinical situation and level of pain, individual risk factors, and the patient’s past experience with particular medications.

Ibuprofen (e.g. Advil, Motrin, Nuprin)

Ibuprofen (e.g. Advil, Motrin, Nuprin)

Ibuprofen was one of the original non-steroidal anti-inflammatory drugs and is available without a prescription. For patients with back problems, ibuprofen is most commonly recommended to relieve mild or moderate back pain, tenderness, inflammation, and stiffness. Common situations in which ibuprofen may be recommended include:

  • Activity-related pain or discomfort (e.g. pain that follows sports, housework, shoveling snow, or other exertion)
  • Pain related to muscle strain in the low back
  • Neck stiffness related to muscle, ligament or tendon strains or damage

Ibuprofen does have some aspirin-like effects on the stomach, so people with active ulcers or sensitive stomachs should avoid ibuprofen. It is best to take ibuprofen with food to minimize the chance of stomach upset. Ibuprofen also has a mild blood thinning effect that lasts a few hours, and can reduce the effectiveness of some blood pressure medications and diuretics (water pills).

The typical recommended dose for ibuprofen is 400 mg taken every eight hours. Prescription doses can be as high as 800 mg of ibuprofen every eight hours.

Naproxen (e.g. Aleve, Naprosyn, Anaprox, Naprelan)

Naproxen (e.g. Aleve, Naprosyn, Anaprox, Naprelan)

Naproxen is available in both non-prescription strength (e.g. brand name Aleve) and prescription strength (e.g. brand name Naprosyn). For patients with back pain, it works by reducing proteins that cause inflammation and pain in the body and is commonly recommended for treatment of back pain.

Naproxen thins the blood, so individuals taking oral blood thinners or anticoagulants should avoid naproxen, as excessive blood thinning may lead to bleeding. Naproxen also can have some adverse gastrointestinal side effects, so people with active ulcers or sensitive stomachs should avoid it. It is best to take naproxen with food to reduce the chance of upset stomach. Notably, naproxen has a potentially fatal interaction with MAOI drugs (e.g. Marplan, Nardil).

The usual adult dose is 250 to 500 mg twice daily using regular naproxen tablets.

COX-2 Inhibitors (e.g. Prescription Brand Celebrex)

COX-2 Inhibitors (e.g. Prescription Brand Celebrex)

This is a newer class of NSAID, which includes the brand name Celebrex. It works by stopping the chemical reaction that leads to inflammation in the body, but (unlike other NSAIDs) does not harm the chemical production of the protective stomach lining. Therefore, COX-2 inhibitors lead to a lower gastrointestinal complication rate than other NSAIDs and do not tend to produce ulcers.

Also unlike other NSAIDs, COX-2 inhibitors do not impair blood clotting, so they are considered safer for patients taking blood thinning medications, such as warfarin (e.g. Coumadin), and they may be used before or after surgery without an increased risk of bleeding.

Important new information from recent studies shows a potentially increased risk for cardiovascular events (such as heart attack and stroke) for COX-2 inhibitors, and the FDA has called for further research. Patients taking COX-2 inhibitors should meet with their physician to determine their individual risk factors for side effects and appropriate treatment options.

Other Forms of NSAIDs

Other Forms of NSAIDs

In addition to the above, NSAID’s come in forms other than taking it orally. For example:

  • Toradol can be given as an intravenous drug, so it is useful after surgery or if the patient cannot eat.
  • Flector can be given as a transcutaneous form of Diclofenac. An NSAID administered through an adhesive patch applied to the skin can be useful because it does not give the patient a large dose of the drug systematically, which can reduce gastrointestinal and other potential side effects of NSAIDs.

Effective Use of NSAIDs

Effective Use of NSAIDs

It is better to use NSAIDs continuously to build up an anti-inflammatory blood level, and the efficacy is markedly lower if taken only when experiencing pain. Taking the drug regularly in the prescribed/recommended dose lets the drug build up over time in order to have an anti-inflammatory effect and allowing the area a better healing environment.

NSAIDs and the pain relief medication acetaminophen (e.g. brand name Tylenol) work differently, so sometimes doctors recommend taking the two medications at the same time. Some people report feeling better pain relief when they take both an NSAID and acetaminophen for their pain.

As with any medication, there are a number of potential risks, side effects and complications that it patients need to be aware of prior to starting to take the any form of the medication.

Two of the more common potential risks and complications of NSAIDs include:

  • Kidney damage. NSAIDs are cleared from the blood stream by the kidney, so it is very important that patients over 65 years of age or patients with kidney disease consult a physician prior to taking the medication. If patients take an NSAID for an extended period of time (e.g. six months or more), a blood test needs to be performed to check for early signs of kidney damage.
  • Stomach problems. NSAIDs may also cause stomach upset or possibly ulcers. Patients with stomach ulcers or a history of stomach ulcers should first consult with their physician. Signs of stomach ulceration and intestinal bleeding typically include one or a combination of the following symptoms: abdominal pain, black tarry stools, weakness, or dizziness upon standing.

Most types of NSAIDs have a variety of other potential risks and complications associated with them. While most side effects are rare, some can be serious and even potentially fatal, so it is important for patients to remain aware of them and under supervision by a health professional.

As a general rule, patients with any of the following factors should be sure to meet with their doctor before taking any type of NSAID:

  • Thyroid problems
  • Diabetes
  • Heart disease
  • High blood pressure
  • Allergy or reaction to aspirin, other NSAIDs or pain relievers
  • Pregnant, about to become pregnant, or breast feeding
  • Consume three or more alcoholic beverages a day
  • About to have surgery or other invasive procedures (including dental surgery)

In order to ensure that NSAIDs are used safely, patients should meet with a physician to evaluate their individual risk factors (e.g. the patient’s likelihood for developing certain health problems, including heart attack, stroke and gastrointestinal problems) and to determine the most appropriate dosages, type of NSAID, and treatment options.

In general, it is recommended that patients avoid taking over-the-counter NSAIDs for more than 10 days in a row without consulting their physician.

As with all medications, patients should discuss with their doctor medications taken (including herbal remedies, supplements, etc), all other medical conditions and allergies. Patients should strictly follow label directions for all pain medications, including non-prescription medications.

As a general rule, patients with any of the following factors should be sure to meet with their doctor before taking any type of NSAID:

  • Thyroid problems
  • Diabetes
  • Heart disease
  • High blood pressure
  • Allergy or reaction to aspirin, other NSAIDs or pain relievers
  • Pregnant, about to become pregnant, or breast feeding
  • Consume three or more alcoholic beverages a day
  • About to have surgery or other invasive procedures (including dental surgery)

In order to ensure that NSAIDs are used safely, patients should meet with a physician to evaluate their individual risk factors (e.g. the patient’s likelihood for developing certain health problems, including heart attack, stroke and gastrointestinal problems) and to determine the most appropriate dosages, type of NSAID, and treatment options.

In general, it is recommended that patients avoid taking over-the-counter NSAIDs for more than 10 days in a row without consulting their physician.

As with all medications, patients should discuss with their doctor medications taken (including herbal remedies, supplements, etc), all other medical conditions and allergies. Patients should strictly follow label directions for all pain medications, including non-prescription medications.

Types of NSAIDs

Types of NSAIDs

Generic name

Brand name(s)

Salicylic Acids
Aspirin (acetylsalicylic acid) Ascriptin, Bayer, Ecotrin
Choline magnesium trisalicylate Trilisate
Diflunisal Dolobid
Salsalate Disalcid, Salflex
Propionic acids
Fenoprofen Nalfon
Flurbiprofen Ansaid
Ibuprofen Advil, Motrin, Nuprin
Ketoprofen Actron, Orudis, Oruvail
Naproxen Aleve, Anaprox, Naprelan, Naprosyn
Oxaprozin Daypro
Acetic acids
Diclofenac Cataflam, Voltaren
Indomethacin Indocin
Sulindac Clinoril
Tolmetin Tolectin
Enolic acids
Meloxicam Mobic
Piroxicam Feldene, Fexicam
Fenamic acids
Meclofenamate Meclomen
Mefenamic acid Ponstel
Napthylalkanones
Nabumetone Relafen
Pyranocarboxylic acids
Etodalac Lodine
Pyrroles
Ketorolac Toradol
COX-2 inhibitors
Celecoxib Celebrex

In addition to the above, certain NSAIDs may also be taken in non-oral forms, such as intravenously or as a transdermal patch. A patch is an adhesive patch applied to the skin – at the area of pain – that slowly releases medication through the skin. The patch that contains the NSAID Diclofenac epolamine is called the Flector Patch.

Neuroleptic drugs are often prescribed to help patients with nerve type pain (which typically shows as leg pain) and for patients who have neuropathy(degeneration of the nerves). These drugs can also be helpful for patients who have continued leg pain after surgery.

While it is not well understood why they help relieve pain, patients may take neuroleptic drugs safely for prolonged periods of time. They are not addictive and are well tolerated by most patients. As an example of a neuroleptic medication, gabapentin (e.g. Neurontin) is commonly prescribed in dosages of 300-400mg taken three times daily. Side effects may include fatigue, dizziness, or nausea.

There are two FDA-approved drugs that have approval to assist patients with quitting smoking.

Zyban
The first anti-smoking drug is Zyban (also known as Wellbutrin) which was originally approved for use as an antidepressant but then also got FDA approval to be marketed as an aid to quitting smoking. It is in the Selective Serotonin Reuptake Inhibitor (SSRI) class of antidepressants, and seems to work by keeping a neurotransmitter (serotonin) around in the brain longer. It can help decrease the craving for nicotine.

It is best used by first starting on Zyban and picking a quit date about two weeks after starting the drug. This gives the body some time to build up the medication in the blood before trying to quit smoking. Zyban may be used in conjunction with a nicotine patch.

Chantix
A newer medication, Chantix, has recently been approved by the FDA to help smokers kick their nicotine addiction. Chantix is a designer drug that has been developed to attach to the nicotine receptors in the brain. Chantix is not nicotine, but if the nicotine receptor in the brain is filled, it seems to cut the urge to continue to smoke.

When taking Chantix, it is not necessary to use nicotine patches to help gradually decrease the addiction to nicotine since the receptor for nicotine is already filled.

It is important to note that there is no one medication or approach to quitting smoking that works equally well for all people. Most research indicates that the most effective approach tends to combine a behavioral treatment (such as anti-smoking support groups or counseling) to address the habit of smoking with ananti-smoking medication to address the physical dependency on nicotine.

While alcohol is sometimes used as a self-prescribed medication to help deal with chronic pain, it probably causes far more problems than it solves and should not be used to treat low back pain. Although alcohol will act as a muscle relaxant, it does not have any actual analgesic (pain killing) effect.

Moreover, from a pharmacology standpoint, alcohol is a major depressant and will exacerbate any preexisting depression and is also dangerously habit-forming (addictive). It is fattening and tends to impede a patient’s overall rehabilitation process. On the whole, large doses of alcohol may seem to help temporarily, but will compound the many already existing problems a patient with chronic pain faces.

Peter F. Ullrich, Jr., MD. “Medications for Back Pain and Neck Pain.” Spine-Health.com. (2011): n. page. Web.
http://www.spine-health.com/treatment/pain-medication/medications-back-pain-and-neck-pain.