Medication For Persistent Pain: NSAIDs

What are Non-Steroidal Anti-Inflammatory Drugs or NSAIDs?

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are a class of medications including ibuprofen, aspirin, diclofenac and naproxen that are commonly used to reduce pain, decrease inflammation, and bring down a fever.

They work by inhibiting enzymes called cyclooxygenases (COX), which play a key role in the formation of prostaglandins—chemicals in the body that promote inflammation, pain, and fever.

Common uses of NSAIDs include pain relief for headaches, muscle aches, arthritis, and minor injuries as well as conditions like arthritis or other inflammatory diseases.

NSAIDs are typically available over-the-counter, though some forms such as Meloxicam, Celecoxib, and Indomethacin may require a prescription for higher doses or longer-term use.

What Type of Pain do NSAIDs Treat?

NSAIDs are versatile medications used to treat a wide range of conditions, primarily by reducing inflammation, pain, and fever. They commonly treat or provide:

Pain Relief

NSAIDs are frequently used for mild to moderate pain, including headaches, toothaches, menstrual cramps (dysmenorrhea), muscle aches (myalgia), back pain, and post-surgical or injury-related pain.

Inflammation

NSAIDs reduce inflammation in various conditions such as arthritis (osteoarthritis and rheumatoid arthritis), bursitis (inflammation of the bursae – small sacs around joints), tendinitis (inflammation of tendons, such as in tennis elbow), sprains, and strains.

Chronic Conditions

NSAIDs are used for longer-term management of chronic inflammatory conditions like osteoarthritis or degenerative joint disease, rheumatoid arthritis, ankylosing spondylitis (a form of arthritis that affects the spine), migraines, or gout (painful joint inflammation caused by uric acid crystals).

How do NSAIDs Alleviate Chronic Pain?

NSAIDs alleviate chronic pain primarily by reducing inflammation, which is often the source or contributor to long-term pain.

Some ways that NSAIDs work to alleviate chronic pain include:

Inhibition of Prostaglandin Production

NSAIDs work by inhibiting an enzyme called cyclooxygenase (COX), which has two main forms: COX-1 and COX-2. These enzymes are responsible for the production of prostaglandins, which are chemicals that promote inflammation, pain, and fever in response to injury or disease.

• COX-1 produces prostaglandins that protect the stomach lining and support platelet function (blood clotting).
• COX-2 produces prostaglandins primarily in response to injury, illness, or inflammation.

By blocking COX-2, NSAIDs reduce the production of prostaglandins associated with inflammation and pain. This reduces the body’s inflammatory response, which is often the root cause of chronic pain in conditions like arthritis.

Reduction of Inflammation

Chronic pain, especially in conditions like osteoarthritis and rheumatoid arthritis, is often driven by persistent inflammation in the joints and surrounding tissues. By reducing inflammation, NSAIDs can:

• Lower swelling and pressure on tissues.
• Reduce stiffness, especially in the mornings.
• Enhance mobility, which can help people with chronic pain move more freely.

This anti-inflammatory action is key to managing long-term conditions that cause pain from ongoing tissue irritation or damage.

Central Nervous System (CNS) Effects

Although NSAIDs primarily work at the site of pain and inflammation, there is some evidence that they may also affect the central nervous system (CNS) by dampening the pain signals sent to the brain. Prostaglandins not only cause local inflammation but also enhance pain perception in the CNS. By reducing prostaglandins, NSAIDs may lower the brain’s sensitivity to pain.

Long-Term Use for Chronic Conditions

In chronic pain conditions like arthritis, tendinitis, or ankylosing spondylitis, NSAIDs are often prescribed for long-term use. This consistent reduction in inflammation helps manage pain over time, although there is a risk of side effects from prolonged use.

NSAIDs alleviate chronic pain by reducing inflammation at its source, blocking the production of prostaglandins responsible for pain and swelling. They help improve mobility, decrease stiffness, and manage symptoms in long-term inflammatory conditions, though care must be taken to avoid problems due to extended use.

Why Would You Take NSAIDs for Chronic Pain?

Taking NSAIDs for chronic pain can provide significant relief, especially when pain is driven by inflammation. Here is why NSAIDs are commonly used in the management of chronic pain:

Effective Reduction of Inflammation

Chronic pain often arises from persistent inflammation, as seen in conditions like arthritis, bursitis, tendinitis, and gout.

NSAIDs are particularly effective because they reduce this inflammation, which in turn reduces pain. By inhibiting the production of prostaglandins (chemicals that cause inflammation and increase sensitivity to pain), NSAIDs help manage the underlying cause of the pain.

Improvement in Mobility and Quality of Life

For individuals with chronic conditions like osteoarthritis or rheumatoid arthritis, the pain and stiffness can significantly impact daily activities. By reducing pain and swelling, NSAIDs allow for improved joint function and mobility and reduced morning stiffness, especially with conditions like arthritis. Overall, NSAIDs may provide a greater ability to perform physical activities, enhancing overall quality of life.

Non-Opioid Pain Relief

NSAIDs offer an alternative to opioids for pain relief, which is particularly important in the context of the opioid crisis. Opioids are highly addictive and come with risks of tolerance and dependence, while NSAIDs do not have these addictive properties.

For long-term pain management, NSAIDs are often preferred because of a lower risk of dependency, making them better suited for long-term use in managing chronic pain associated with inflammation.

Ease of Access and Use

Many NSAIDs, like ibuprofen, naproxen, and aspirin, are available over-the-counter and are relatively inexpensive compared to some other pain-relief options. This makes them convenient for individuals seeking relief from chronic pain without needing frequent prescriptions.

Acute Flare-Ups in Chronic Conditions

Chronic pain conditions can have periods of acute flare-ups where pain and inflammation become more severe. NSAIDs can be particularly useful during these times to quickly reduce inflammation and provide temporary relief. For example, NSAIDs help manage the acute pain and swelling during a gout flare-up, or they can be taken during periods of increased joint inflammation due to arthritis flares.

Chronic Arthritis

In chronic conditions like osteoarthritis and rheumatoid arthritis, NSAIDs are a first-line treatment to manage symptoms, as they relieve joint pain and stiffness, help preserve function in affected joints by reducing inflammation, and allow patients to maintain physical activity, which is important for long-term joint health.

NSAIDs Target Inflammation and Pain

Unlike other pain relievers (such as paracetamol), which mainly block pain signals without addressing inflammation, NSAIDs directly reduce the inflammatory processes that contribute to chronic pain. This dual effect makes them more suitable for conditions where inflammation is the primary cause of pain, like in tendinitis, bursitis, and autoimmune diseases (such as lupus and rheumatoid arthritis).

NSAIDs are commonly taken for chronic pain because they effectively reduce both pain and inflammation, improving mobility and quality of life for people with chronic inflammatory conditions.

They offer a non-addictive, accessible option for pain relief and are particularly beneficial for those with arthritis, tendinitis, and other inflammation-driven pain conditions. However, long-term use should be monitored due to potential side effects.

Risks of NSAIDs

While NSAIDs are generally considered safe, they do pose some risks especially in regard to long-term use. These risks include side effects such as:

• Gastrointestinal Issues. Long-term NSAID use can cause nausea, gastritis, stomach ulcers and gastrointestinal bleeding, especially because COX-1 inhibition reduces the protective lining of the stomach. To minimise these risks, people with chronic pain may use COX-2 selective inhibitors (e.g., Celecoxib), which specifically target COX-2 enzymes responsible for inflammation while sparing COX-1, thereby reducing gastrointestinal side effects. However, it is to be noted that COX-2 inhibitors whilst reducing the risk of gastrointestinal side effects, do not completely eliminate the risk.
• Kidney Problems. Prolonged use of NSAIDs can affect kidney function by reducing blood flow to the kidneys.
• Cardiovascular Risks. Some NSAIDs, especially at high doses, can increase the risk of heart attack or stroke over time.
• Liver Damage. While liver toxicity is less common with NSAIDs than with other pain medications (like acetaminophen), it can still occur, particularly with prolonged or high-dose use. In rare cases, NSAIDs can cause liver injury, leading to elevated liver enzymes, jaundice, or, in severe cases, liver failure.
• Allergic Reactions and Hypersensitivity. Some individuals may experience allergic reactions to NSAIDs, particularly aspirin-sensitive asthma sufferers. These reactions can include rashes or hives, breathing difficulty, or even anaphylaxis in extremely rare cases.
• Bleeding and Blood Clotting. NSAIDs, especially aspirin, can interfere with the blood’s ability to clot by inhibiting platelet function. This can result in increased bleeding risk and post-surgical complications.
• Bone Healing. There is some evidence that long-term use of NSAIDs might slow down the healing of bones after fractures or surgeries, particularly in people recovering from orthopaedic injuries.
• Medication Interactions. NSAIDs can interact with other medications, which can increase the risk of side effects or reduce the effectiveness of other treatments. For example, NSAIDs can increase the risk of bleeding in people taking anticoagulants like warfarin or interact with ACE inhibitors and diuretics and worsen kidney function.

While NSAIDs are effective for managing pain and inflammation, they are not without risks, especially with long-term or high-dose use. The most common risks include gastrointestinal issues, kidney problems, cardiovascular risks, and increased bleeding. People with preexisting conditions or who take other medications should use NSAIDs under medical supervision to minimise these risks.

Due to the increased risks of using NSAIDS continuously or long term, Dr Mittal advises intermittent use of NSAIDS (For eg: to manage a flare up of pain or use 2-3 times a week as a rescue medication) for individuals suffering from chronic or persistent pain.

Finding a Persistent Pain Doctor Near You

If you are suffering from mild to moderate chronic pain, an NSAID medication regimen may work for you.

To find a doctor near you who treats persistent or chronic pain, ask your general practitioner for a referral to a pain management physician.

Also, you can research pain management clinics online or speak to family members, friends, or support groups (both online and in real life) for recommendations; those who have dealt with similar chronic pain issues or other problems may have valuable advice to offer.

Non-steroidal anti-inflammatory drugs can alleviate some types of pain, providing a higher quality of life for patients dealing with chronic pain conditions that have not responded well to other treatments.