Pharmaceuticals

Non-Prescription Medicines (general sales and pharmacy only)

Pain relief can be taken at the same time as having osteopathy. Some traditional nonsteroidal anti-inflammatory drugs (NSAID's) such as ibuprofen (Nurofen, I-Profen, Act-3 and generic), diclofenac (Voltaren), naproxen (Naprogesic, Sonaflam) and menfenamic acid (Ponstan) are available over the counter. Naprogesic is marketed in New Zealand for the treatment of period pain and Sonaflam for musculoskeletal pain, though they both have the same active ingredient (Sonaflam is cheaper than Naprogesic). Pontsan is marketed in New Zealand for the treatment of period pain, though it is also effective at reducing musculoskeletal inflammation. Nurofen Zavance Liquid capsules and Act-3 Liquid Ibuprofen are claimed to be absorbed twice as fast as standard ibuprofen. Ibuprofen lysine is more soluble in water than apo-ibuprofen. Do not take more than one type of NSAID at the same time (aspirin is also a NSAID). NSAID's do not address the root cause of inflammation, but they do temporarily reduce inflammation and give some relief of symptoms while the body's self healing process takes place. There is no evidence that they decrease recovery time of back pain. Osteopathy does address the underlying causes of back pain, and does decrease the recovery time. Because of the risk of ulcers and gastrointestinal bleeding, do not exceed the recommended dose, and talk with your doctor or osteopath about using this medication for a long time. Ibuprofen is less likely to cause side effects than diclofenec. The application of topical agents such as a NZAI gel (i.e. Voltaren Emugel, Nurofen Gel, Oruvail Gel, Powergel, Feldene P Gel) can help reduce inflammation without risk of side-effects. Deep heat has been shown to be ineffective.

Paracetamol (Panadol, Paracare) helps relieve mild to moderate pain. Panadeine, Panadeine Extra, Panafen Plus and Paracode are over the counter medications that contains paracetamol and codeine and therefore give stronger pain relief than paracetamol alone. Panadeine and Paracode both contain 500 mg paracetamol and 8 mg of codeine, Panafen Plus contains 500 mg paracetemol and 12.5 mg codeine and Panadeine Extra contains 500 mg paracetamol and 16 mg of codeine. Panadol Extra contains 500 mg paracetemol and 65 mg caffeine, which makes it more effective. A similar effect can be obtained by taking paracetemol with a strong cup of coffee or an energy drink, and a stronger effect by taking a combination paracetemol/codeine with a coffee or energy drink. Caffeine is a stimulant and can prevent sleep, so shouldn't be taken within 6 hours of bedtime. With Panadol, Panadol Extra, Panadeine, Panadeine Extra, Paracode and Panafen Plus an adult or children over 12 should take two tablets every 4-6 hours, with a maximum of 8 tablets in 24 hours. Children 7 to 12 should take half to one tablet every 4-6 hours, with a maximum of 4 tablets in 24 hours. Childen under 7 should not take paracetamol or codeine except under medical advice. The higher dose of codeine in Panadeine Extra may cause drowsiness and/or constipation. Constipation can be avoided by taking Alpine Tea by Red Seal (from the herbal tea section at supermarkets), or lactulose syrup (from a pharmacy). Do not take codeine for more than three days without medical advice. Do not take with another medication containing paracetamol or codeine. A stronger effect may be obtained by combining a pain killer such as Panadeine, Paracode, Panafen Plus or Panadeine Extra with a NSAID such as Nurofen. Nuromol contains 500 mg paracetemol and 200 mg ibuprofen and Maxigesic contains 500 mg paracetemol and 150 mg ibuprofen, making them good all-in-ones. Nurofen Plus and Ibucode Plus both contain 200 mg ibuprofen and 12.8 mg codeine. Nurofen Plus and Ibucode Plus can be taken at the same time as paracetemol. Codeine as a stand-alone medicine is only available on prescription.

Pain relief when pregnant. Any type or amount of NSAID (including ibuprofen and diclofenac) increases the risk of miscarriage by 2.4%. Opiates (including codeine) are best avoided in pregnancy. In the first trimester there is a small risk of opiates causing miscarriage or malformations. In the third trimester they may cause fetal physical dependence and withdrawal. Paracetemol has an extremely small risk of liver damage and death, but is probably the safest analgesic to take when pregnant. However it is not very effective on it's own in relieving moderate to severe back pain. Please take the advice of your doctor before taking any medicine if you are pregnant.

Prescription Only Medicines

NSAID's. There are two categories of nonsteroidal anti-inflammatory drugs (NSAID's). Tradititional NSAID's are nonselective COX inhibitors, that is they inhihibit two isoforms of the enzyme cycloxygenese, COX-1 and COX-2. Examples are ibuprofen (Nurofen), diclofenac (Voltaren), naproxen (Noflam), ketoprofen (Oruvail), sunlidac (Daclin), tenoxicam (Tilcotil), peroxicam (Candyl-D), tiaprofenic acid (Suram) and indomethacin (Rheumacin). Examples of COX-2 inhibitors are celecoxib (Celebrex), and etoricoxib (Arcoxia). COX-2 is found at the site of inflammation, while COX-1 is found in most tissues and helps maintain the normal lining of the stomach. Inhibiting COX-1 can cause gastic irritation, ulcers, prolonged bleeding time and kidney problems. However some COX-2 inhibitors (Vioxx and Bextra) have been withdrawn because of a small increase in the risk of a heart attack or stroke, and all of them can produce side effects such as GI upsets, though the incidence is less than with conventional NSAID's. Meloxicam (Mobic) is claimed by its manufacturer to be COX-2 selective, but it is an oxicam (other COX-2 inhibitors coxibs) and in reality inhibits both COX-1 and COX-2. It is found at higher levels in synovial joints than other body fluids, making it particularly effective for treating sprained joints and arthritis. Meloxicam and COX-2 inhibitors are unfunded by the New Zealand government, though most tradititional NSAD's are funded. For Meloxicam or COX-2 inhibitors to be funded by ACC, your doctor will need to apply for advance consent using an ACC1171 form.

Strong analgesics (pain killers) such as codeine, tramadol (Tramal), dihydrocodeine (DHC Continus), pethidine, morphine, and oxycodone (OxyContin) are helpful in managing severe back pain. They are all addictive and have side effects such as drowsiness and constipation. Ask your doctor if you can drive a motor vehicle or use machinery if you are taking strong analgesics. Codeine is effective for the relief of mild to moderate pain, and is often taken with paracetemol. Tramadol is a synthetic analog of codeine and is between codeine and morphine in potency, but causes fewer side effects than opioids due to it's dual opioid and monoaminergic actions. Dihydrocodeine is similar in potency to Tramadol but with typical opioid side effects (it is also an effective cough suppressant). It isn't often used in New Zealand for pain management. Pethidine is sometimes used clinically for the short term relief of moderate to severe acute pain. Oxycontin is used for more severe acute pain and similar in analgesic and adverse effects to morphine. In New Zealand oxycontin is sometimes used to relieve the pain of bone fractures, but not usually for back pain. Oral liquid morphine is more often used to relieve acute severe back pain (on a controlled drug prescription). Due to their constipating effects of opioids, it is a good idea to take a laxative such as lactulose syrup with them. Contrary to popular belief strong analgesics do not simply mask pain and cause people to do things they shouldn't and make their condition worse. They enable people with severe pain to move, which helps them lead a normal life and speed up recovery and helps to prevent chronic pain. Strong analgesics should not be used for prolonged periods unless all other therapies such as osteopathy have been tried, and then only as part of a pain management program. If you suffer from severe pain your osteopath will tell you what activities you can do and what you should avoid.

Muscle relaxants: back muscles do not usually get injured, but muscle spasm can be a consequence of a back injury, and may contribute to pain. Muscle relaxants such as orhenadrine citrate (Norflex), dantrolene (Dantrium), baclofen (Alpha-Baclofen) and diazepam (Valium) can help people with severe back pain move around, which can speed up the healing process. All are funded by the New Zealand government. Baclofen and diazepam can cause drowsiness and are addictive. Do not drive a motor vehicle or use machinery if taking baclofen or diazepam. Orhenadrine citrate is an anticholinergic drug that is both a muscle relaxant and an analgesic. Muscle relaxants can result in a loss of a protective posture and gait, which can sometimes lead to the aggravation of an injury. For example, a small disc bulge could fully prolapse and press on a nerve root, causing sciatica. Muscle relaxants are usually used in conjunction with analgesics and sometimes NSAI's. Muscle relaxants are of no help for less severe back pain.

Amitryptyline (Amitrip) is a older type of antidepressant called a tricylic that, in low doses, can be useful in treating chronic pain. It is more effective in treating fibromyalgia and chronic back pain of neuropathic origin than musculoskeletal injuries. It is best taken at night as it can cause drowsiness. It can also cause a dry mouth. It is funded in New Zealand. Never stop taking amtryptyline without talking to your doctor first as you may experience withdrawal symptoms such as headaches, nausea or low energy.

Gaberpentin (Neurontin) is an anticonvulsant drug usually prescribed for the treatment of epilepsy. Pain specialists sometimes prescribe it for neuropathic pain. It is funded in New Zealand. Side effects include fatigue, amnesia, balance problems, dry mouth, dizziness, confusion, water retention and weight gain. Do not stop this drug abruptly. Decrease the dose slowly over time, under medical supervision.

Steroids: oral steroids (Prednisolone) can help reduce the symptoms of acute sciatica, but are rarely used as they can cause serious side effects. Stopping steroids must be done carefully under medical supervision. Steroid injections (hydocortisone) into the epidural space have not been found to decrease duration of symptoms or improve function and are not currently recommended for the treatment of acute back pain without sciatica Injections of hydrocortisone with a local anaesthetic into the facets joints or intervertebral discs may be beneficial for people with severe low back pain associated with sciatica, though symptoms tend to reoccur some months later. In New Zealand these injections are usually preformed by musculoskeletal specialists. Facet joint and disc injections by musculoskeletal specialists are not funded by Public Health but they are available on ACC, though they they are not fully funded, so a co-payment is payable. You will need a referral from your osteopath or GP. Steroids reduce inflammation but also kill the cells that renew damaged connective tissue, and damaged connective tissue is usually part of the problem. Osteopaths doesn't recommend more than one steroid injection into one specific site within one year. It is recommended to also have osteopath treatment to correct the underlying biomechanical dysfunction that has led to the presenting symptoms. Trigger point injections have not been proven helpful in acute back pain. Trigger point injections with a steroid and a local anaesthetic are sometimes used to treat chronic back pain. Their benefit is unproven and their use remains controversial.

Natural Remedies

Natural Anti Inflammatories

The following herbs, enzymes and oils taken orally may help reduce inflammation, and can be taken at the same time as having osteopathic treatment:

Curcuma longa (tumeric extract)

Boswellia serrata (frankinsence)

Zinzibar officianale (ginger)

Harpagophytum procumbens (devil’s claw)

Enzymes such as papain and bromelain

Omega 3 fatty acids (fish oil/marine lipids)

Joint Repair Supplements Supplements

The following nutritional supplements may help repair damaged joints, and can be taken at the same time as having osteopathic treatment:

Chondroitin sulfate

Glucosamine sulfate

Manganese picolinate

MSM (Methyl sulfonyl methane)

There is some anecdotal evidence that freeze dried porcine or bovine intervertebral disc tissue and liquefied bovine tracheal cartilage taken orally can help speed up the healing of inter-vertebral disc problems.

Magnesium

Magnesium is a natural muscle relaxant. Although Epsom salts are magnesium sulphate, it is not a good idea to take them orally as they are poorly absorbed and often cause diarrhoea. Magnesium is best taken in a chelated form for good absorption and bio-availability. Magnesium citrate is a very good form. You should take about 150 mg of magnesium (elemental weight), twice a day. Long term supplementation of just magnesium can lead to calcium depletion and osteopenia or osteoporosis (different degrees of low bone density). Do not take magnesium for more than three months unless part of a comprehensive nutritional program formulated by an expert such as Philip Bayliss.

Philip can give you advice on these nutritional supplements and can obtain high quality supplements for you (Thorne Research and Metagenics).

Herbal Rubs

Massaging the painful area with a cream that containing some or all of the following may be helpful:

Ruta graveolens (common rue)

Rhus toxicodendron (poison ivy)

Stellaria media (chickweed)

Arnica montana (leopard's bane)

Symphytum officinale (comfrey)

Lavendula angustafolia (lavender oil)

Vibrational Remedies

If you have a sudden onset of severe pain, you could try taking the homoeopathic remedy arnica 6X or the Bach Flower Remedy: Rescue Remedy as soon as possible after the onset. If taking arnica, let 2 tablets dissolve under the tongue, and avoid coffee or mints. If taking Rescue Remedy, drop a couple of drops under the tongue every 2 hours. Please note that Dr Bach was Welsh, not German, so the name Bach should be pronounced the same way as that of a New Zealand holiday home.

Cannabis, narcotics, psychedelics and alcohol

In the New Zealand Health Survey, Cannabis Use 2012-13, 42% of adults aged 15 years and over admit having smoked cannabis, with 11% percent reporting using cannabis in the last 12 months, with 34% of those becoming addicted i.e. using it at least weekly. 42% claimed that they smoked for medicinal purposes. 36% of users admitted driving while 'high' in the last 12 months. Driving under the influence of cannabis is associated with increased risks of motor vehicle collisions and associated injuries. Recently there has been considerable research into the medical effects of cannabis (marijuana, dope, grass, weed, pot). The endocannabinoid system plays an important role in fundamental brain developmental processes such as neuronal cell proliferation, migration and differentiation. There are cannabinoid receptors throughout the brain. Cannabinoids (THC and CBD) interact with specific receptors in the brain and immune system, which reduce pain and inflammation. There is no evidence that cannabis helps relieve acute (short duration) back pain. It may be useful to alleviate chronic (long term) back pain, neuropathic pain, cancer pain and pain due to spacticity caused by cerebral palsy (CP), stroke and spinal cord injury. Cannabinoids can help with disturbed sleep (though in some people it may cause it) and it also helps with poor appetite and decreases nausea caused by chemotherapy. It may help glaucoma, head trauma, irritable bowel disease (IBS), post traumatic stress disorder (PTSD), and children who suffer epileptic seizures. Cannabinoids may limit neurological damage in patients with Alzheimer's disease and Parkinson's disease. However prenatal or adolescent exposure can lead to altered brain development, and also possibly exposure before conception. The babies of adult mice given cannabinoids a long time before conception have altered neural circuitry due to epigenetic changes altering DNA expression of both parent and child. The same may occur in humans. Smoking cannabis in childhood can lead to mental illnesses such as schizophrenia for those with a genetic predisposition, which may not otherwise be expressed, or an earlier onset and more severe psychosis in those who would have developed it anyway. Young users also have a higher incidence of personality disorders. Cannabis users frequently report a feeling of well-being and relaxation using the drug, but regular users have higher rates of depression, anxiety and suicidal thoughts than non-users. Motivation, attention and short term memory can be affected. Users are more likely to leave school without qualifications, less likely to go to university, and less likely to graduate if they do go to university. People who smoke cannabis have more respiratory problems such as asthma, chronic cough and bronchitis. The Christchurch Health and Development Study (CHDS) and the Dunedin Multidisciplinary Health and Development Study (DMHDS) together followed the lives of over 1000 NZ children from birth to adulthood. They report that by the age of 21 nearly 80% of young people have used cannabis on at least one occasion and 10% of thosebecame addicted i.e using it at least weekly. Their research shows that regular use through teenage years impairs brain development and lowers intelligence, causing an IQ drop of around 8 points. If the teenager doesn't stop while still young, the loss is permanent. This doesn't happen to people who start using in their 20s. An average person has an IQ of 100, which is the 50th percentile for intelligence. If a user loses 8 IQ points, they drop to the 29th percentile for intelligence. Other illicit drug use is over 100 times higher amongst adolescent weekly users of cannabis when compared with non users. Cannabis may be a ‘gateway drug’ increasing the risks of other forms of drug usage. To summarize, cannabis does seem to benefit some medical conditions, but it also has strong negative effects, especially for young people who should avoid it completely (with the possible exception of juvenile epilepsy, and then under medical supervision).

Narcotics such as opioids are very effective analgesics but are highly addictive and dangerous and should only be used under medical supervision.

Psychedelic drugs and ecstasy (MDMA) may in some circumstances be strong analgesics. There are anecdotal reports of users receiving severe injuries and not noticing them and of patients with terminal cancer temporarily becoming indifferent to severe pain, but their powerful consciousness altering effects means that they can't be safely used as a treatment for back pain. There are reports of remarkable improvements in multiple sclerosis (MS) patients taking MDMA.

Amphetamines and cocaine do not have analgesic qualities. Cocaine used to be used as a local anaesthetic.

Alcohol has a very mild analgesic effect in very large quantities, but it also has side effects including poor balance and poor judgement, giving the possibility of injury and increased pain. It is fine for an adult suffering from back pain to have one or two drinks in the evening to help induce relaxation. Alcohol should be avoided or reduced with some prescription only drugs (check the label).

Philip Bayliss, Registered Osteopath, 43 Thames Street, St Albans, Christchurch, NZ. ☎️03 356 1353