In the past, now approaching three years since the onset of the pandemic, people having their elective surgeries delayed, sought out anti-inflammatories as the means to hold them over until surgery day. With little other choice, so they thought, all they could hope to do was to reduce their swelling and hold on. For some people that may have been the best option. For others it may not have been the optimal choice. Let me explain.
Over twenty years ago, I wrote in my book the Collagen Revolution, that the body’s natural healing response is inflammation. If you stopped inflammation. You stopped healing. Therefore you needed inflammation to heal but you needed inflammation to be controlled so that excessive swelling and chronic inflammation did not in of itself cause joint degeneration.
Inflammation is the trigger for the cascade of events that follow in wound and injury repair. In my opinion, the moment inflammation became the enemy of healing, is the moment chronic pain started becoming a billion-dollar business for drug companies. When Ibuprofen was introduced in 1974, it was heralded as one of the great steps in the management of pain. By 1976, two years after its introduction, 1.7 billion tablets had been produced. Today, millions of prescriptions for pain relievers are written annually and tons of aspirin are consumed each day. Yet chronic pain persists. Why? Because these drugs only mask the problem of pain and do not attempt to cure it.
Furthermore, these drugs come with their own risks of addiction and unpleasant side effects. If you suffer from myofascial pain, joint pain, arthritis, sprained or strained ligaments, almost any kind of pain, most likely your doctor will prescribe one of the non-steroidal anti-inflammatory drugs, or NSAIDs. These drugs will reduce the inflammation, which in the short-term reduces the pain. However, in the long-term they set you up for more pain and long-term chronic injury and worse.
Why You May Win the Pain Battle, BUT Lose the Pain War
Understandably, people do not like to feel pain and would like to prevent it at all costs. People want immediate relief and getting rid of the inflammation often provides that relief. Further, with surgeries delayed, anti-inflammatories were seen as necessary if not essential to patient well-being. What was the cost of that temporary well-being? The basic truth is that immediate relief does not equal long-lasting relief. Interfering with the body’s healing process by stopping inflammation to reduce pain causes long-term suffering down the road. Inflammation does cause pain, but, pain can be your friend. It is the body’s siren alerting you that you have injured yourself. Getting rid of inflammation with NSAIDs provides some immediate relief from pain. It sets you up to win the battle, but lose the war.
By stopping inflammation we shut down the body’s natural healing which inhibits the growth of new tissue. In our practice, many alarmed patients have had to stop the use of NSAIDs because of stomach discomfort, nausea, and dizziness.
Inflammation, and the accompanying pain, are actually your allies in healing.
In my book of more than 20 years ago I went on to explain: Unfortunately, this is where chronic problems begin, because the conventional medical practice with its emphasis on pain relief, treats the symptom—pain, and not the problem—joint and spine instability brought on by ligament weakness. A patient will likely be told to take anti-inflammatory drugs, which is often precisely the wrong thing to do because inflammation is the first part in the body’s healing process. Nonsteroidal anti-inflammatories NSAIDS and cortisone (an anti-inflammatory steroid) can give immediate relief, but with a risk of creating a long-term injury with chronic pain. By blocking inflammation, anti-inflammatories never allow complete healing, and instead, aggravate the situation.
Twenty years later “Using anti-inflammatory drugs and steroids to relieve pain could increase the chances of developing chronic pain”
Now, let’s read from a press release issued in May 2022 from McGill University in Canada.
“Using anti-inflammatory drugs and steroids to relieve pain could increase the chances of developing chronic pain, according to researchers from McGill University and colleagues in Italy. Their research puts into question conventional practices used to alleviate pain. Normal recovery from a painful injury involves inflammation and blocking that inflammation with drugs could lead to harder-to-treat pain.
“For many decades it’s been standard medical practice to treat pain with anti-inflammatory drugs. But we found that this short-term fix could lead to longer-term problems,” says Jeffrey Mogil, a Professor in the Department of Psychology at McGill University and E. P. Taylor Chair in Pain Studies.
In the study published in Science Translational Medicine, (1) the researchers examined the mechanisms of pain in both humans and mice. They found that neutrophils – a type of white blood cell that helps the body fight infection – play a key role in resolving pain.
“In analyzing the genes of people suffering from lower back pain, we observed active changes in genes over time in people whose pain went away. Changes in the blood cells and their activity seemed to be the most important factor, especially in cells called neutrophils,” says Luda Diatchenko a Professor in the Faculty of Medicine, Faculty of Dentistry, and Canada Excellence Research Chair in Human Pain Genetics.
Inflammation plays a key role in resolving pain
“Neutrophils dominate the early stages of inflammation and set the stage for repair of tissue damage. Inflammation occurs for a reason, and it looks like it’s dangerous to interfere with it,” says Professor Mogil, who is also a member of the Alan Edwards Centre for Research on Pain along with Professor Diatchenko.
Experimentally blocking neutrophils in mice prolonged the pain up to ten times the normal duration. Treating the pain with anti-inflammatory drugs and steroids like dexamethasone and diclofenac also produced the same result, although they were effective against pain early on.
These findings are also supported by a separate analysis of 500,000 people in the United Kingdom that showed that those taking anti-inflammatory drugs to treat their pain were more likely to have pain two to ten years later, an effect not seen in people taking acetaminophen or anti-depressants.”
In the companion article Anti-inflammatory medication side-effects – accelerated knee osteoarthritis, I write about patients being pain managed with anti-inflammatory medications and painkillers, and the one question they all seem to have is: “What are these medications doing to my knees.” Possibly they are worsening your knee damage.
While NSAIDS can make knees feel better in the short-term, more and higher doses are needed to in the long-term to achieve similar results. In the over 22 years that we have treated patients with knee problems, there has always been the instance when a patient will ask us if they can continue with their anti-inflammatory medications. The answer is typically no. When the patient asks why? We remind them that regenerative medicine techniques like the ones we use, count on the beneficial aspects of inflammation. Inflammation is the way Nature heals. If we stop the inflammation, we stop the healing.
In my article Research comparing different types of knee injections, I discuss various injections that may help. These include: platelet rich plasma (PRP), corticosteroids, mesenchymal stem cells (MSCs), and hyaluronic acid. Each injections is discussed within the latest research.
“The clinical management of inflammatory pain requires an optimal balance between effective analgesia and associated safety risks.”
A recent paper wrote: “Existing guidelines for pain management provide recommendations that do not satisfactorily address the complex nature of pain. To achieve optimal outcomes, drug choices should be individualized to guarantee the best match between the characteristics of the patient and the properties of the medication. NSAIDs represent an important prescribing choice in the management of inflammatory pain, and the recent results on paracetamol (Tylenol) question its appropriate use in clinical practice, raising the need for re-evaluation of the recommendations in the clinical practice guidelines.” (6)
The reality of anti-inflammatory use and how doctors can help
A March 2022 paper (2) writes about the reality of anti-inflammatory use and how doctors can help: “The use of NSAIDs in osteoarthritis treatment, either planned by a medical professional or taken of the patients’ own accord, is very high. Two-thirds of the (study) population affected by osteoarthritis are over 65 (which is the standard age of retirement in Hungary), which carries the risk of comorbidities and the parallel use of several medications, but a considerable fraction of osteoarthritis patients is still active, for whom immediate and long-lasting pain management is both medically and financially important. Both general practitioners and specialists need to familiarize themselves with their patients’ pain management habits and make a comprehensive and personalized plan for the management of osteoarthritis patients.”
Non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, intra-articular corticosteroid injections are of little value in the long term, and opioids may have ominous consequences.
A study from 2022 (5) writes about the need for new knee pain treatments: “Non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, intra-articular corticosteroid injections are of little value in the long term, and opioids may have ominous consequences. Radiotherapy of knee osteoarthritis has no added value. Physical therapy, exercises, weight loss, and lifestyle modifications may give pain relief, improve physical functioning and quality of life. However, none of them has articular cartilage regenerating potential. . .(in this paper the researchers) focus on emerging osteoarthritis knee treatments, relieving symptoms, and regenerating damaged articular cartilage that includes intra-articular human serum albumin, conventional disease-modifying anti-rheumatic drugs (DMARDs), metformin, lipid-lowering agents (statin), nerve growth factors antagonists, bone morphogenetic protein, fibroblast growth factors, Platelet-Rich Plasma (PRP), Mesenchymal Stem Cells (MSC),” and other treatments. We will be discussing some of these treatments in this article and the research published by other investigators.
A brief discussion of aspirin
Many patients we see have been taking aspirin for years because it had at one time helped them with their joint pain. Many of these people ask when they come into our office if it is okay to continue taking the aspirin. After all, they say, people have been taking low-dose aspirin for years to help reduce the risk of heart attack. Low dose aspirin can be an appealing self-help treatment for some people. They have joint pain, they have become more sedentary and they have gained more weight. There is a heart health concern for many that they believe the low dose aspiring will be helpful for. What does research say about aspirin?
Recent trials evaluating the effect of aspirin in the primary prevention of cardiovascular disease showed little or no benefit
A November 2021 study (3) already acknowledging that “Recent trials evaluating the effect of aspirin in the primary prevention of cardiovascular disease showed little or no benefit,” explored if in some patients, the daily or chronic use of aspirin actually contributed to the risk of incident heart failure. Taking data from 30,827 patients at risk for heart failure the researchers found that in patients at risk of heart failure, aspirin use was associated with greater likelihood of heart failure. They concluded: “that aspirins should be prescribed with caution in patients at risk of heart failure or having heart failure. This is a controversial subject.
A January 2020 study (4) writes: “The need for aspirin therapy as part of primary prevention of cardiovascular disease is currently being highly debated, especially after 3 studies in different settings reported that a reduction in ischemic events is largely counterbalanced by an increase in bleeding events.” In other words the protective benefits of aspirin were offset by bleeding. The researchers also write: “When patients are less than 70 years of age, clinicians should assess the 10-year cardiovascular risk. Aspirin treatment should be considered only when the cardiovascular risk is very high and the bleeding risk is low, after taking into account the patient’s preferences.”
These studies make general recommendations. It is strongly suggested that any changes to your use of aspirin be discussed with your doctor.
Do you have questions about your treatment options? Ask Dr. Darrow
Marc Darrow, MD. JD., discusses the treatment philosophy of the Darrow Stem Cell Institute. Transcript of video
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1 Parisien M, Lima LV, Dagostino C, El-Hachem N, Drury GL, Grant AV, Huising J, Verma V, Meloto CB, Silva JR, Dutra GG. Acute inflammatory response via neutrophil activation protects against the development of chronic pain. Science Translational Medicine. 2022 May 11;14(644):eabj9954.
2 Mezey GA, Máté Z, Paulik E. Factors influencing pain management of patients with osteoarthritis: A cross-sectional study. Journal of Clinical Medicine. 2022 Mar 1;11(5):1352.
3 Mujaj B, Zhang ZY, Yang WY, Thijs L, Wei FF, Verhamme P, Delles C, Butler J, Sever P, Latini R, Gf Cleland J, Zannad F, Staessen JA; Heart Omics in Ageing Investigators. Aspirin use is associated with increased risk for incident heart failure: a patient-level pooled analysis. ESC Heart Fail. 2021 Nov 22. doi: 10.1002/ehf2.13688. Epub ahead of print. PMID: 34808706.
4 Aimo A, De Caterina R. Aspirin for primary prevention of cardiovascular disease: Advice for a decisional strategy based on risk stratification. Anatolian journal of cardiology. 2020 Feb;23(2):70.
5 Cao X, Cui Z, Ding Z, Chen Y, Wu S, Wang X, Huang J. An osteoarthritis subtype characterized by synovial lipid metabolism disorder and fibroblast-like synoviocyte dysfunction. Journal of orthopaedic translation. 2022 Mar 1;33:142-52.
6 Varrassi G, Alon E, Bagnasco M, Lanata L, Mayoral-Rojals V, Paladini A, Pergolizzi JV, Perrot S, Scarpignato C, Tölle T. Towards an effective and safe treatment of inflammatory pain: a Delphi-guided expert consensus. Advances in Therapy. 2019 Oct;36(10):2618-37.