"Broadly speaking, back pain is
caused by tissue damage of the facet joint or the
intervertebral disc. You can reduce the pain from a bad back in two ways when using back pain medications: by working locally to damp down pain by reducing the inflammation at the site of trouble. Or, you can reduce pain by modifying perceptions
of pain at a higher level in the brain. Back pain drugs that work at local level at
the site of inflammation are called ‘non-steroidal anti-inflammatory drugs’ or NSAIDs,
such as ibuprofen. On the other hand ‘painkillers’ such as Paracetamol work at
brain level, although nobody is quite sure how this drug works."
So says our guest authority, Dr Peter Lacey.
Dr Peter Lacey
"The tissue damage at local level leads to bleeding and swelling. That swelling stimulates pain nerve fibre endings. Messages about the tissue damage and inflammation are conducted along the nerve pathways to the spinal cord. They then travel up to the spinal cord to the brain where they are registered as pain. Various protective mechanisms such as ‘protective muscle spasm’ come into play, which may also need to be controlled by back pain medication.
Protective 'muscle stiffness' is a defence mechanism that the body puts in place to stop the damaged part being hurt any further by movement before it’s ready. Un-remitting spasm can become a source of pain in its own right, constituting a third factor that can add to the pain."
"So, in summary, there is local pain caused by tissue damage, the brain’s processing of that pain and the spasm that sets in. All three can fuel each other in a vicious circle of pain, spasm and immobility. The principles of pain relief in low back pain are to break that vicious circle. Luckily for us, there are well established and researched back pain medications that can be used on all three contributors to pain at local level, brain level and spasm.
Tissue Damage and Inflammation at Local Level
"The body does not like blood outside a blood vessel. Blood is irritating to the tissues and that’s why a bruise is painful. Tissue damage causes the release of complex chemicals such as prostaglandins at the seat of pain to bring on inflammation and swelling. This stimulates an increase in the blood supply to the damaged tissue and helps to promote speedy repair. Inflammation, though painful, plays an invaluable role at the site of damage. By reducing the production of inflammatory chemicals, you can reduce the swelling and diminish the pain signals sent to the brain.
"The group of back pain medications that works best to reduce inflammation at local level are 'non-steroidal anti-inflammatory drugs' or NSAIDs. Commonly used NSAIDs are Ibuprofen, [Brufen, Advil, Nurofen] and Diclofenac [Voltaren, Voltarol, Fenac] and the father of them all, Aspirin.
"With using NSAIDS, we are looking to reduce the local inflammation without completely switching it off. We do this by using the right doses of NSAIDS regularly for a few days. As I've said, the repair mechanism has to fit in somewhere, because inflammation is not a completely useless process. The right dose makes the pain tolerable while not completely impeding repair. The right dose knocks the peak off the pain by dampening it down a bit.
Central Pain: The contribution to pain and spasm by the brain and spinal cord
"We humans are so predictable when it comes to using medications. My patients always say to me: “If you can buy it at the supermarket or over the counter it can’t be any good for me. I want the best and only my doctor can prescribe that”.
Question: Do you know the name of the best and safest centrally-acting painkiller we have? Is it Codeine perhaps, or Morphine, or Pethidine?
Answer: It’s none of the above. It is Paracetamol.
Paracetamol is very effective taken regularly. Two tablets every four to six hours is ideal so that you are not waiting for the pain to return. It is particularly good to have this medication cover while you are doing something physical to try to fix your back problem - and this will help you switch off the pain and get on with your life.
Paracetamol is a highly effective painkiller in low back pain medication
"Paracetamol is probably been the most under-rated painkiller or pain-controller of all time. Even pain specialists have cottoned-on to this fact in the last few years. Increasingly, it is being used intravenously for post-operative pain relief because it doesn’t make you sleepy [that’s not the same as allowing you to sleep because the pain has gone away] doesn’t make you constipated and you can’t become addicted to it. What’s more, you can buy it at the supermarket and you don’t need a prescription from someone like me.
Just a word of warning though. Don’t use more than eight a day though. Even Paracetamol has its drawbacks. Taking more than eight a day can lead to liver damage.
Protective Muscle Spasm
The second brain controlled mechanism that needs to be modified and reduced in the first few hours and days of acute back pain is muscle spasm. It’s a brain controlled response that starts off with good intentions, but the vicious circle almost short-circuits itself and the mechanism needs a 12 Amp fuse to break it and reset it.
Protective muscle spasm gives you a stiff-feeling rigid back interspersed with 'growling twinges' if you move suddenly
Not many doctors like prescribing Diazepam (Valium) these days. It has rather a bad reputation, with names such as ‘mother’s little helper’ or ‘the little yellow pill’. It is more addictive than morphine and heroin and consequently it can be very difficult to get people off.
Valium is a scourge in prisons, where addiction amongst inmates is rife and the curse of withdrawal, violence and addiction is hard to deal with. But Diazepam has one saving grace: it can play a pivotal role in the arsenal of back pain medication. It is unsurpassed in controlling centrally mediated back spasm. If used carefully, it will break the cycle of back pain by giving you a holiday from the hard, painful clench of the back muscles in spasm - and this will help your back move more easily and the pain to lift.
Most pain caused by tissue damage in the back can be dealt with by these three groups of drugs: anti-inflammatories, Paracetamol and a few days – no more of Diazepam. Very few people will need more than this combination."
It is very important for you to know that you can also relieve back pain by using physical techniques designed to evacuate inflammatory products and switch off over-active muscles. In fact, all back pain medication works best if you are taking physical measures to help rectify the problem at the same time. You can read all about these techniques in How to Relieve Back Pain
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