Australians use over the counter medication for convenient pain relief. Paracetamol, non-Steroidal anti-inflamatory medications (Voltaren, Neurofen, Ibuprofen etc, referred to here as NSAIDS) and some of these products boosted by codeine are the all too often the first line of defence when we strain our back, feel a headache coming on, or sustain another musculoskeletal ache or pain. For your GP, chemist or average healthcare consumer, it’s what we have learned to reach for when seeking relief. Now that codeine is prescription only, what do you plan to do? Are there any alternatives? Is there a better way to manage some of these conditions, especially if they are chronic/recurrent?
There are several options in the Australian healthcare system for the management of aches and pains. Over the counter drugs or prescription drugs are certainly one option. But are they safe? More importantly, do they even work? And lastly, should they be the first treatment choice?
Let’s consider a leading cause of disability around the world: Low Back Pain. It's also the number 1 reason people visit a chiropractor...not to mention the doctor, physio or chemist. Many large scale trials and systematic reviews, not to mention recent international guidelines, now recommend against the first line use of opiates, which is the category that codeine falls into, for conditions such as low back pain, acute or chronic.
What is surprising is that they also recommend against the use of paracetamol and NSAIDS! A growing body of research has demonstrated that the risks associated with these drugs is larger than the benefit. For example, a high quality systematic review found paracetamol to be no more effective than placebo for acute low back pain. The evidence does not seem very strong for chronic low back pain, either. What about NSAIDS? Well, there are some problems, here, too. NSAIDS improve pain and disability, but not that much when compared to a placebo.. It's estimated that 6 people with back pain need to be treated with NSAIDS, rather than placebo, in order for 1 person to benefit in a clinically important way. The risk, however, is there are 2.5 times as many gastrointestinal side effects, There are also increased risks of cardiovascular events, especially in a person with greater risk of cardiovascular disease.
There is some evidence that topical NSAIDS might be safer, with fewer and less risky side effects for conditions like osteoarthritis.
As for opioids, the risk vs benefit is moving further and further away from suggesting their use. Consulting a GP may increase the likelihood of receiving a prescription, however, you may be worse off for it later.
Many guidelines now recommend other, more conservative first line treatments for back pain and headache. Spine related conditions may benefit from treatment provided by a Chiropractor, such as heat, soft tissue massage, exercise, advice and spinal manipulation. Furthermore, early evidence is being published that draws an interesting association between provider care, and use of opioids for low back pain.
In, "Association Between Utilization of Chiropractic Services for Treatment of Low-Back Pain and Use of Prescription Opioids," Whedon and colleagues found the following:
Objective: Pain relief resulting from services delivered by doctors of chiropractic may allow patients to use lower or less frequent doses of opioids, leading to reduced risk of adverse effects. The objective of this investigation was to evaluate the association between utilization of chiropractic services and the use of prescription opioid medications.
Design: The authors used a retrospective cohort design to analyze health insurance claims data.
Setting: The data source was the all payer claims database administered by the State of New Hampshire. The authors chose New Hampshire because health claims data were readily available for research, and in 2015, New Hampshire had the second-highest age-adjusted rate of drug overdose deaths in the United States.
Subjects: The study population comprised New Hampshire residents aged 18–99 years, enrolled in a health plan, and with at least two clinical office visits within 90 days for a primary diagnosis of low-back pain. The authors excluded subjects with a diagnosis of cancer.
Outcome measures: The authors measured likelihood of opioid prescription fill among recipients of services delivered by doctors of chiropractic compared with nonrecipients. They also compared the cohorts with regard to rates of prescription fills for opioids and associated charges.
Results: The adjusted likelihood of filling a prescription for an opioid analgesic was 55% lower among recipients compared with nonrecipients (odds ratio 0.45; 95% confidence interval 0.40–0.47; p < 0.0001). Average charges per person for opioid prescriptions were also significantly lower among recipients.
Conclusions: Among New Hampshire adults with office visits for noncancer low-back pain, the likelihood of filling a prescription for an opioid analgesic was significantly lower for recipients of services delivered by doctors of chiropractic compared with nonrecipients. The underlying cause of this correlation remains unknown, indicating the need for further investigation.
In conclusion, there is no simple solution towards complex, common problems, such as spinal pain, low back pain and headache. However, evidence is currently tipping towards alternative treatments, such as those provided by a chiropractor, physio or osteopath as a first stop for such complaints. Good lifestyle habits inclusive of quality sleep, increased exercise and decreased stress are always helpful in the management of these conditions. Medication may play a role, however, options are now limited due to risks of adverse events and low scientific efficacy in the management of spinal pain. Treatment from a chiropractor may be warranted in acute bouts of back pain.
 GBD DALY’s and HALE Collaborators, Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016, The Lancet. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32130-X/fulltext
 ELS C et al, Adverse events associated with medium- and long-term use of opioids for chronic non-cancer pain: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017 Oct 30;10:CD012509. doi: 10.1002/14651858.CD012509.pub2..https://www.ncbi.nlm.nih.gov/pubmed/29084357
Stochkendahl MJ et al, National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018 Jan;27(1):60-75. doi: 10.1007/s00586-017-5099-2. Epub 2017 Apr 20. https://www.ncbi.nlm.nih.gov/pubmed/28429142