Medications for Back Pain

by Zinovy Meyler, D.O.

Different medications used to control back pain fall into different categories. Now, the broad spectrum of the categories can be broken down initially into the way we take the medication itself. So, oral medications, those that can be used as topical medications, and those that need to be injected.

So, to talk about the oral medications, which are more commonly used as an initial treatment. Over-the-counter medications that control the pain, such as Tylenol, can be used to control the pain itself. Now if we are to actually employ the use of the anti-inflammatory and pain control, we can seek the aid of non-steroidal anti-inflammatory medications/drugs (NSAIDs). The most common ones are ibuprofen, naproxen, and the common brand names are Aleve, Motrin, Advil.

The other medications that can be used are steroids. If there is a lot of inflammation that causes the back pain, oral steroids can be employed. Now, generally, we don’t like to use oral steroids for a variety of reasons – they don’t tend to help pain that is axial, or in other words pain that is limited to the actual back without radiating into the extremities. So, we are actually using the steroids very sparingly because it has systemic effects - although minimal, but it does - and as with any treatment, we try to minimize the systemic effect or any side effect by achieving the highest yield in terms of relieving pain. So, steroids can be used, but are not commonly used.

Another type of medication is narcotic medication. Now, narcotic medications are opioids and they are used to dissociate the patient from the pain. They are usually used for severe, acute pain. They are meant to be used for a short period of time, such as the initial injury, or initial trauma, or initial onset of the most acute pain or they can be used in post-operative pain control. Another group of medications are muscle relaxants. Now, muscle relaxants are used to decrease the tone of the muscles and the reason to use them is because in many cases of back pain, muscle spasm is what usually accompanies it.

Another oral medication that can be used to control back pain is antidepressants and a variety of antidepressants can be used. An example of those would be tricyclic antidepressants or antidepressants like Cymbalta.

So, there are certain medications that can be used by just putting it directly on the skin over the area that is affected and that can be helpful. The benefit of these medications is that it is directly applied to where the pain is and where the injury is. The medications are either anti-inflammatory or pure painkillers. So the pure painkillers are things like lidoderm patch, which is lidocaine that is slowly released through a patch through the skin and that can be applied to used to just numb up the area and reduce the localized pain. Another type is the use of diclofenac, which is one of the older non-steroidal anti-inflammatory medications and that can be used in the form of a patch as Inflector patch or in the form of a cream, such as Voltaren or other formulations. The benefit of this is that it is localized and systemic absorption is quite limited. That limitation is the fact that it only penetrates a certain depth and so really the use is, to an extent, limited.

Another group of the medications are the medications that are injected and there are really two of the main ones that are used for back pain. One is non-steroidal anti-inflammatory medication that can be injected, such as Toradol, and that’s injected into the muscle and the effect is systemic - or in other words it affects the whole body - in reducing the pain and its anti-inflammatory action. Another one is anesthetic, which is anesthetic like lidocaine, bupivacaine, or any other form of an anesthetic that is used to numb up the area. That can be used either to break up a muscle spasm or to numb up an area so that other manipulations can be performed in order to relieve the pain.

Another medication that can be used as an injectable is a steroid. A corticosteroid, as opposed to an oral corticosteroid, goes directly to where the problem is. So, it doesn't have to be systemically absorbed - it bypasses the systemic effect - even though it is systemically absorbed to a small degree, but it bypasses the major systemic side effects and its concentration doesn't have to be diluted by all the processes that have to happen in our body in order to get that medication to the source of the pain.

So, that really is a general overview of the medications we can use in controlling, and relieving, and in treating back pain.
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Texas will not take the mark of the beast

'Anti-Something' Protesters At Texas State Capital, April 18, 2020

No, COVID-19 isn't like the Flu

Anti-Quarantine Protest in Olympia, Washington

“When enough insane people scream in harmony that they really are healthy, they can actually start to believe themselves. Or put even more simply: people with overlapping delusions get along wonderfully.” (Daniel Mackler, Toward Truth, 2010)

From my friend Everett Daniel Maroon, who writes this for anyone who needs to hear it:

1. People dying from the flu over a 7-month period vs. the same number of people dying from COVID-19 over a 6-week period is an important difference.
2. People dying from cancer in hospice or at home vs. people dying in an ICU bed is a big difference in terms of hospital resources.
3. People dying from accidents, gun shot trauma, homicides vs. people dying from a communicable disease is a huge difference in risk to the community.
4. People dying from a communicable disease that we HAVE treatments and cures for vs. people dying from a communicable disease that has no vaccine or curative treatment is a catastrophic difference.
5. People dying from a disease we know about (smallpox, rabies) vs. people dying from a disease we don't yet fully understand is WHY WE TELL PEOPLE TO STAY AT HOME.
6. Acting like these differences don't matter is exactly why governmental leaders around the globe have ordered us to stay home.
7. This is not a Jay Inslee issue. It is not ultimately a Donald Trump issue. Please stop acting like there is nothing different about this novel coronavirus.

First Do No Harm!

PURPOSE

The purpose of this post is to describe the similarities and differences between the symptoms and diagnostics that might be used to distinguish between COVID-19 and pericarditis. I'm interested in this because, as I've described in some detail in a prior post, I've experienced acute pericarditis and still suffer from its effects.

In addition, fatalities associated with COVID-19 are overwhelmingly associated with the elderly and people with existing chronic or temporary medical conditions, such as heart disease, lung disease, asthma, the flu, or other preexisting conditions. Of course, COVID-19 will also target people who may have compromised immune systems, including those compromised by medications they may be taking to treat a preexisting condition, such as patients suffering an acute attack of pericarditis being treated with prednisone, a corticosteroids which, like others, suppresses the immune system.

COVID-19

In 2019, a new coronavirus was identified as the cause of a disease outbreak that originated in China.
The virus is now known as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease it causes is called coronavirus disease 2019 (COVID-19).

The signs and symptoms of COVID-19 compiled by WebMD based on information gathered from researchers in China, included:

• Fever 83%-99%
• Cough 59%-82%
• Fatigue 44%-70%
• Lack of appetite 40%-84%
• Shortness of breath 31%-40%
• Mucus/phlegm 28%-33%
• Body aches 11%-35%

 Symptoms usually begin 2 to 14 days after one comes into contact with the virus.

Other symptoms may include:

• Sore throat
• Headache
• Chills
• Stuffy nose
• Nausea or vomiting
• Diarrhea

Some people have experienced the loss of smell or taste.

PERICARDITIS

The Mayo Clinic describes pericarditis is swelling and irritation of the pericardium, the thin sac-like membrane surrounding the heart. Pericarditis often causes chest pain and sometimes other symptoms. The sharp chest pain associated with pericarditis occurs when the irritated layers of the pericardium rub against each other.

Depending on the type pf pericarditis, its signs and symptoms may include some or all of the following:

• Sharp, piercing chest pain over the center or left side of the chest, which is generally more intense when breathing in
• Shortness of breath, especially when reclining
• Heart palpitations
• Low-grade fever
• An overall sense of weakness, fatigue or feeling unwell
• Cough
• Abdominal or leg/feet swelling

Many of the symptoms of pericarditis are similar to those of other heart and lung conditions, including COVID-19.

COVID-19 or PERICARDITIS?

I am day 11 into COVID-19. I'm in the emergency room with severe chest pain and breathing problems. ER nurse said my heart and lungs may be inflamed. My ECG is "abnormal." My pulse is strong. I can’t get to my regular doctor because of the lock-down here. In the last 2 days since my visit to ER I have felt dizzy and nauseous. I have pain in middle of my chest and a panicky fluttery feeling. Now I have a really sore throat. Is this now pericarditis?

Answering the question of this patient on the basis of this information isn't straight-forward. As the symptoms described in the previous sections show, COVID-19 and acute pericarditis symptoms mirror each other closely. This is further illustrated in Table 1, below.

Research indicates that the most common cause of idiopathic pericarditis "in developed countries" is a virus of unknown specificity, thus the diagnosis "non-specific idiopathic pericarditis." Deriving from the severe acute respiratory syndrome coronavirus 2, COVID-19 may well trigger pericarditis, or in a patient with the pre-existing condition, a pericarditis flare up. On the other hand, patients with pre-existing cardiac conditions, like pericarditis, may be more susceptible to COVID-19 because of a disease-induced depressed immune systems, or because a treatment protocol for their pericarditis depresses their immune system, e.g., prednisone (see Figure 1).

Fig. 1. Complementary relationship between COVID-19 and Pericarditis

One of the key ways humans encode and then retrieve information is by labeling and compartmentalizing it, e.g., this disease manifesting these symptoms is COVID-19. This disease manifesting these symptoms is the flu. This disease manifesting these symptoms is pericarditis.

The lay person gets the sniffles concludes they have a cold, the sniffles evolves to a cough, fever, and achy body and they lament having contracted the flu. But in the midst of a SARS-CoV-2 pandemic, they might fear they've come down with COVID-19.

In diagnosing any given patient with the objective of learning and then treating the source of their misery it's imperative that physicians understand (and most do) that the patient is a living history of all that ails them. A patient that presents with flu-like symptoms, is experiencing shortness of breath, and has sharp chest pain, must give a full health history, be examined, and be given a complete laboratory workup to sort out the source of their misery, realizing that it may be generated by a combination of linked factors, i.e., COVID-19 and pericarditis. The course of treatment depends on doing this. Otherwise it might do more harm than good.