Low Back Pain Drug Summary, Coursework Example

Abstract

This paper provides a thorough summary of drugs and medications being used to treat low back pain. In order to understand the condition, treatment and management, this paper discusses the diagnosis, the disease process, doses, routes, administration of the drugs pharmacology, pharmacokinetics, drug interactions, cost of therapy, research trend, adverse effects and other ways of how to manage and treat pain.

Low Back Pain Drug Summary

Low back pain is one of the most common health problems that are being experienced not just by the elderly but as well as people from all walks of life. This condition easily impairs its victim in the most significantly negative way. It limits the capabilities and capacity of a person to do activities of daily living and reducing the quality of life. Also known as lumbago, this condition is one of the most common reasons of physicians visits not just in Canada but as well as in the United States of America. As a matter of fact, it is rated to be the fifth primary reasons for doctor’s visits in the United States alone. Studies have revealed that about 40% have been affected by this disorder. It is revealed that this condition is associated with a pain felt in the bones and muscles found in a person’s back. This condition is mostly caused by an injury, stress, and even a disease. Unfortunately, this condition can last for up to 12 weeks. Therefore, the diagnosis is based on its duration: acute pain to last up to 6 weeks and chronic pain that could last for up to 12 weeks. Further classification is made to include the cause to be either non-mechanical, mechanical and referred pain. There are many known causes of low back pain including the irritation of the nerve roots that can be found in the lower part of the back, the impairment of the muscles, ligaments, bones and joints in the back and the degeneration of the intervertebral disc. Not to mention that fibromyalgia, inflammatory as well as bone conditions are also attributed as one of the causes of lower back pain.

Although there are various classifications connected with low back pain, clinical practices and diagnosis have publicized that most of the patients have non-specific low back pain. This only means that the back pain being experienced cannot be attributed or blamed for certain disease or specific back abnormality. In this regard, there are many types of medications that are being made available and prescribed as part of treatment. This is due to the fact that even the simplest medication can have a severe side effect to the user. The cost of the treatment can be very expensive reaching as high as $26.3 billion to $200 billion per year. This does not include the compensation and losses both the patient and company can acquire from back injuries on an annual basis. This is due to the fact that about 3-4% of the working population in the United States is disabled temporarily due to lower back pain while about 1% of the same population is permanently disabled due to the same condition (Katz, 2006). With this, these groups of people are causing an economic burden as they require government support for disability and compensation until the pain is managed enough to go back to work.

However, the challenge lies on finding the specific therapy or treatment to be used in order to weigh the benefits and harms. In addition, it cannot be denied that pieces of evidence as well as researches have exposed that cost of medications and the preferences of patients affect the choices and the selection of treatments.  In 2007, the American Pain Society with the collaboration of the American College of Physicians released a guideline that physicians can refer into when providing and recommending first line of treatment and diagnosis of low back pain. In this regard, doctors are prescribing NSAIDs and acetaminophen as first line of treatment.

Acetaminophen, popularly known as paracetamol, is one of the most widely used non-prescription pain killer in the whole world. Due to its availability and affordability, people can easily have access to it to try and control not just headaches but as well as back pain. This is one of the first-line of treatments of low back pain because it is better tolerated by the body as compared to other non-steroidal anti-inflammatory drugs (NSAIDs). However, acetaminophen might not be as effective as the NSAIDs in managing pain especially when someone is already used to it. Its usage is only effective when treating minor pain and aches.

Importantly, acetaminophen is primarily metabolised in the liver and therefore, the chances of getting liver disease is high although this drug is only considered to be a mild analgesic due to its metabolites named as phenacetin and acetanilide. Hence, the recommended safe daily dosage is 4g that can be taken orally or intravenously. It must be noted, though, that a small overdose on this medication can be deadly. Yet, highest dosage are being given in order to manage sever pain associated with post-surgical procedures and other major pain. This medication is promptly absorbed by the body through the GI tract. The distribution by volume is usually 50L and after 4 hours, the concentration drops from the amount of 30µg/ml to a lesser amount of 10µg/ml (Trelle, 2011).  Although the manner of action of how this medication work is uncertain, it is generally acknowledged inhibiting COX-1 and COX-2 by virtue of metabolism caused by the peroxidase task of the isoenzymes. But it cannot be denied that this medication lacks that efficacy to treat lower back pain. The reason being is that it only has very limited anti-inflammatory components and activities. It does not have enough strength and capability to inhibit pro-clotting thromboxane production. This medication highly interacts with ketoconazole and can interfere with laboratory tests resulting in the acquisition of false data. Another drug that cannot be used alongside acetaminophen is warfarin which is a blood thinning medication. Acetaminophen can also thin blood and using it alongside warfarin can cause increased bleeding.

In this regard, it is of utmost important that monitoring is done to ensure that the efficacy and toxicity of the medication is managed very well. For example, in the case of poisoning of overdose of paracetamol, an assessment needs to be immediately done. The medical ABC is followed which means check for the airway, the breathing and status of the fluid in the body. Knowledge with the drug interaction is likewise important especially when there is a potential deadly drug interaction involved such as co-ingestions of salicylate.

The determination of its toxicity is done through the administration of AC or activated charcoal within the first hour of poisoning or overdose. The risk of hepatotoxicity is determined by drawing of a 4-hour acetaminophen concentrated serum whose values are interpreted by the use of the Rumack-Matthew nomogram. Once a determination is made that the acetaminophen levels are above the safe lever, patients are admitted to the hospital right away and will be treated with NAC or N-acetylcysteine. Patients with symptoms of hepatic failure, encephalopathy, coagulopathy and metabolic acidosis are treated in the intensive care unit. In some cases, an organ transplant is necessary.

NSAIDs also known as non-steroidal anti-inflammatory drugs are also regarded as first line treatment of low back pain because of its analgesic component. When given in high dosage, this medication produces anti-inflammatory effects. Also, this drug is being used as first line of treatment of low back pain because it is a good alternative to narcotics. NSAIDs are non-narcotic drugs. Popular drugs under this medications include ibuprofen, aspirin and naproxen; all of which are readily available over-the-counter in most and certain countries in the whole world. NSAIDS are divided into two categories known as selective and non-selective. These two categories function differently. The former has the ability to inhibit the COX-2  and the latter has the capability to inhibit both the COX-1 and COX-2.

NSAIDs act as cyclooxygenase 1 and 2 inhibitors resulting in the synthesis of two major components known as thromboxanes and prostaglandins. It is believed that the anti-inflammatory, antipyretic and analgesic components of NSAIDs are the result of the inhibition of COX-2 activities. However, studies revealed that the inhibition of COX-1 caused by NSAIDs can cause bleeding in the gastro-intestines and ulcers due to the lowering of prostaglandin levels in the stomach. There are various groups of drugs that are under the NSAIDs category such as salicylates (aspirin and dolobid), propionic acid derivatives (naproxen and ibuprofen), enolic acid derivatives (piroxicam and tenoxicam) and acetic acid derivatives (sulindac and tolmetin) (Edmunds & Mayhew, 2013). These drugs might have same tolerability but they all differ in their efficacy depending on the dosage and route of administration. Some might cause lower risk of bleeding while others might be a big contributor of myocardial infarction.

It should be noted that just like acetaminophen, non-steroidal anti-inflammatory drugs only have a 3-5 pKa which makes them weak acids. Upon the administration, ingestion and absorption of these drugs in the stomach, their distribution by volume is associated with the plasma volume as they are protein-bound in the albumin or plasma. Liver metabolizes NSAIDs and therefore excessive usage can lead to renal failure and other associated diseases and health conditions even in the administration of normal and recommended dosage. This is particularly true when taking NSAIDs with ciclosporin used to treat certain diseases such as autoimmune, colitis and arthritis. NSAIDs taken with ciclosporin can potentially cause liver and kidney damage. It can also diminish the effect of aspirin as a blood thinner. It is safe, however to use diuretics with NSAIDs under close monitoring by a physician to avoid kidney damage. In addition, NSAIDs combined with lithium inhibits the body to rid of lithium especially for people who are using lithium for bipolar disorder and depression treatment.

Some selective NSAIDs such as Vioxx and Bextra were recalled due to their contribution to increasing risk for heart attack. A warning has also been released concerning the use of selective NSAIDs by people who are suffering from coronary artery disease or history of heart attack chest pain, stroke and even narrowed brain arteries. Like in any other drug usage and administration regardless of the nature, there is a need for monitoring and proper management in order to ensure that the risk does not outweigh the benefits.

Yet, depending on the symptoms and the severity of the pain, opiods or narcotics are being prescribed although it is more potent and susceptible to drug abuse. This is but another proof that the management of low back pain as well as its treatments are in its worse. It is undeniable that the treatment for low back pain is costly with the inclusion of over usage in order to manage the pain and do activities of daily living comfortably without having to suffer from so much pain. In some studies and researches conducted, it has been shown that demographics contribute to back pain. It is found out that out of the estimated 440 million visits to physicians, 58% of the patients were female between 49 to 53 years of age. In addition, there is a decrease in the usage of NSAIDs per visit from 37% to 25% while an increase of narcotics usage per visit from 19% to 29% was recorded (Hoy, 2014). This only means that people are now opting to get prescription for narcotic usage such as Tylenol 3 with codeine and other opiate pain killer such as Vicodin, Percocet, Dilaudid, Astramorph and OxyContin among other for pain management. These opiate pain killers act as a perception suppressor wherein upon administration it immediately calms ones senses of pain. This is its way of diminishing the pain signals and the reaction of the brain to the pain signals. But then again, it cannot be denied that even though may people attest to the benefits of the opiate painkillers there are still side effects to it that warrant a close monitoring and administration by a physician or a registered health practitioners.

In this regard, it can be seen that instead of the administration of the first line of treatments such as acetaminophen and non-steroidal anti-inflammatory drugs, many physicians are increasingly prescribing narcotics with the goal of successfully managing pain.

With regard to the treatment and management of lower pain, doctors and health professionals should go back to the basic of getting a full medical history of the patient with an inclusion of a complete physical examination (x-ray, CT or computerized tomography, myelograms, discography, MRI or magnetic resonance imaging, blood test and bone scans to name a few) in order to understand and get into the bottom of the pain. A proper diagnosis should be given in order to determine the right treatment to get (Mehling, 2011).

In summary, it can be seen that drugs such as acetaminophen and non-steroidal anti-inflammatory drugs are being used as a first line of treatment of low back pain because of its availability and affordability. However, the recommended dosage must be followed due to the fact that it can cause potential life-threatening situation such as kidney failure, liver diseases, death due to overdose and even myocardial infarction. Sometimes, the risks and the harmful side effects of the drugs outweigh the benefits that one can get from taking too many medications.

Education is also a key component to managing low back pain. It should be remembered that prevention is better than cure. People, employed or unemployed, must be given education on proper body mechanics when working and how to live healthily and prevent conditions related to pain. The society must not start running towards medication and narcotics to manage their pain because drug dependence is as bad as pain in itself. It is understandable to take medications for pain because it impairs a person’s ability to function and diminishes quality of life. There are many ways to manage and treat pain and it should all be promoted to ensure quality of life (Tilbrook, 2011).