My purpose of writing this edit column every week is to educate the general public on medicine, or more aptly the dangers of medicine. I would be remiss in my task, if I did not talk about the dangers of pain killers.So far, patients have been subjected to pill popping by all and sundry, which is understandable if they’re getting the advice from a lay person.
But doctors literally thinking that pain killers were safer then aspirin switched to the dictum of `take two at night and call me in the morning’ if the call made to the doctor was because of pain. This was because medicinal science at the time of the emergence of these drugs gave doctors the impression that they were the safer alternative. Down the line we have come to realise that this is far from true. Nevertheless, the difficulty in educating people is that it may all be too technical. In which case I’d hope to at least bring this to doctors’ attention, especially those who use and prescribe these left, right and centre.
One must understand why these pain killers – called non-steroidal Anti-inflammatory drugs (NSAIDs) are hazardous. A study conducted as early as 2002 by William Abraham and his colleagues published in the New England Journal of Medicine tells us that NSAIDs worsened heart failure in 7,227 patients.
I still see a fair amount of unwarranted NSAID usage. In essence in NSAID acts on muskeloskeletal pain and joints by suppressing a chemical substance called prostaglandin.There are some good prostaglandins that are protective to the blood supply of the heart and brain, and suppressing them leaves these organs at risk.
I have often been asked in the heyday of NSAID usage about which is best and several medical papers address such issues, but to no real definitive conclusion. About 60 per cent of patients will respond to any NSAID, others that do not respond to one molecule may respond to another for no obvious reasons.
Pain relief starts after taking the first dose.The full analgesic effect takes about a week. The anti-inflammatory effect may take up to three weeks.
It is estimated that in 2013 over 100 million prescriptions were written for NSAIDs alone. In the early 2000s concerns with pain killers called COX 2 inhibitors, Rofecoxib and Valdecoxib were noted and in September 2004 the United States’ FDA declared a black box warning for Valdecoxib.
The manufactures voluntarily withdrew Rofecoxib from Western markets. The earlier generation of NSAIDs have also undergone scrutiny and several studies have shown an increased risk with Diclofenac and subsequent studies incriminate Ibuprofen particularly for stroke and Naproxen for heart disease. A subsequent study analyzing 58,000 patients from the Danish National registry demonstrate a hazard ratio of 2.57 for Celecoxib, 1.5 for Ibuprofen, 2.4 for Diclofenac.
Another Danish study suggested that even short-term therapy with most NSAIDs of 7 to 14 days is dangerous in heart patients because it increases the risk of sudden death and a recurrent heart attack and many blunt the effect of blood thinners, such as aspirin.
Studies for the risk of stroke with NSAIDS are less clear but do tell us that Ibuprofen and Diclofenac use is associated with a higher risk of stroke. As I understand Diclofenac has been withdrawn in the USA and exists only in the gel form.
So now what? Do we let the patient suffer pain, irrespective of the drugs’ ability to help ease it? The magic of drugs like Diclofenac in relieving pain is well known and I have taken this myself for a toothache, years before it was declared unsafe. Here clearly the doctor has the responsibility of explaining to the patient, the hazards of such drug usage.
Many do not and in fact GPs administer such drugs by injection increasingly, for the fear of losing his patient to the next-door competitor who will do so, to prove his healing is better. The answer in ethical medicine terms is, pills only when necessary. Safer (usually less effective) pills first, before deciding on dangerous pain killers–and when these are prescribed, it should be for the shortest possible time.
The American Heart Association recommends Paracetmol, aspirin, Tramadol, and narcotic agents before proceeding to non-acetylated salcytates and select NSAIDs such as naproxen, before proceeding down the line.
I have of late been asking all my patients in the ICU whether they took such pain killers in the last few week and many have replied that they have. I wouldn’t want to lose my life from medication, and I assume neither do you. So please proceed with caution.