When NSAIDs make pain worse
In this article, Ross Hauser MD explains why chronic non-steroidal anti-inflammatory drug (NSAIDs) usage can make pain worse in the long-term and accelerate the need for joint replacement.
I want to start this article with a study on alternatives to NSAIDs usage. I am hopeful this study will help you understand the role of NSAIDs and how its anti-inflammatory action can make your pain worse and how a pro-inflammatory activity, in this case, exercise, may help lessen your pain.
Research 1: Stopping NSAIDs usage is seen as a way to help patients avoid joint replacement surgery and worsening pain
Researchers at the University of New England and the Center for Molecular Medicine at the Maine Medical Center Research Institute published a report in the journal Arthritis and rheumatology.(1) In this report they wanted to examine evidence that exercise, commonly recommended for patients with osteoarthritis pain is beneficial. Especially, they wanted to know, if exercise is beneficial in situations where the pain is chronic and persistent, resistant to non-steroidal anti-inflammatory drugs, and associated with advanced osteoarthritis.
So they looked at laboratory rats and put them through a series of tests including a vigorous treadmill exercise program for 4 weeks. What they found was exercise induces pain relief in advanced, NSAID-resistant osteoarthritis, likely through increased endogenous opioid signaling. Endogenous opioids are the natural brain chemicals our bodies make to fight pain. Endogenous means from within. The most famous of these brain chemicals are endorphins. Not only do endorphins help alleviate pain but they also reduce anxiety and enhance mood. People who run long distances are familiar with the term, “runner’s high.”
One more thing, not only did the exercise release these natural painkillers we have inside us, but the treadmill exercise also secreted chemicals that blocked certain bone loss and helped with a potential bone-stabilizing effect on the osteoarthritis joint. In other words, the exercise helped block part of the joint bone erosion seen in advanced osteoarthritis.
- So bringing this forward, and this is something we have seen many times in the many years we have seen patients, here we have someone in pain, they are taking anti-inflammatories because they and their health care providers believe inflammation is at the core of the problem. The pain persists, the NSAIDs are replaced by exercise felt much better.
Research 2: Stopping NSAIDs usage is seen as a way to help patients avoid joint replacement surgery and worsening pain
At the Veteran’s Affairs of the Connecticut Healthcare System and Yale School of Medicine, a study is underway. The study is titled:
- Discontinuing a non-steroidal anti-inflammatory drug (NSAID) in patients with knee osteoarthritis: Design and protocol of a placebo-controlled, noninferiority, randomized withdrawal trial.(2)
The hypothesis of this study, that is what the researchers are confident they will find is that a placebo will be just as effective as meloxicam, a commonly prescribed anti-inflammatory medication.
- If the researchers can show this, then they can show, NSAIDs do not offer benefit and the need and way to get patients to stop using NSAIDs must be explored.
This is from the study:
- “Knee osteoarthritis is the most common cause of knee pain in older adults. Despite the limited data supporting their use, non-steroidal anti-inflammatory drugs (NSAID) are among the most commonly prescribed medications for knee osteoarthritis.”
- The use of NSAIDs for knee pain warrants careful examination because of toxicity associated with this class of medications. . .This study is the first clinical trial to date examining the effects of withdrawing an NSAID for osteoarthritis knee pain. If successful, this trial will provide evidence against the continued use of NSAIDs in patients with osteoarthritis knee pain.”
Research: The reason a joint replacement is recommended is because NSAIDs do not work. In fact, NSAIDs usage accelerated the pain that led to joint replacement recommendation.
Below is a quote from research in the medical journal Pain. In this statement, doctors suggest that the reason a joint replacement is recommended and performed is because NSAIDs do not work and, in fact, cause the pain that leads to joint replacement recommendations.
- “Difficulty in managing advanced osteoarthritis pain often results in joint replacement therapy. Improved understanding of mechanisms driving NSAID-resistant ongoing osteoarthritis pain might facilitate the development of alternatives to joint replacement therapy. Our findings suggest that central sensitization (a heightened sense of pain) and neuropathic features contribute to NSAID-resistant ongoing osteoarthritis joint pain.”(3)
In our practice, we see patients of all ages. We see the high school athlete, we see the great-grandparent. If both have knee problems – from sports-related injury or age deterioration, both prior to their visit with us, they will likely be prescribed an NSAID. Why? Because doctors believe that NSAIDs still offer the best of both worlds – an anti-inflammatory medication and a pain reliever.
As such, NSAIDs are still considered the first-line treatment for osteoarthritis-related pain despite significant side effects including PREVENTING HEALING and ACCELERATE osteoarthritis and joint deterioration.
NSAIDs prevent healing and send patients to joint replacement surgery is not a new idea, Caring Medical published research of 2010
In 2010, I published the following paper in the Journal of Prolotherapy. The Acceleration of Articular Cartilage Degeneration in Osteoarthritis by Nonsteroidal Anti-inflammatory Drugs. (4) In this research I stated:
The use of this nonsteroidal anti-inflammatory medication has been shown in scientific studies to accelerate the articular cartilage breakdown in osteoarthritis. Use of this product poses a significant risk in accelerating osteoarthritis joint breakdown. Anyone using this product for the pain of osteoarthritis should be under a doctor’s care and the use of this product should be with the very lowest dosage and for the shortest duration of time. If NSAID use continues, then most likely the exponential rise in degenerative arthritis and subsequent musculoskeletal surgeries, including knee and hip replacements as well as spine surgeries, will continue to rise as well.
And as far back as 1995, in a classic study from the University of North Carolina, School of Medicine, Division of Orthopaedic Surgery, Sports Medicine section found how detrimental NSAIDs use was in healing soft tissue. The paper also stated a fact that many researchers in this field are still wondering, “Despite the lack of scientific data, NSAIDs are widely used, often as the mainstay of treatment.”(5) More than twenty years later – little has changed.
NSAIDs a false sense of healing makes things worse
From the above studies, it is clear that NSAIDs inhibit the individual’s chance of healing. NSAIDs are used because they decrease pain, but they do so at the expense of hurting the healing of the injured soft tissue. A good example of this is a study on the use of Piroxicam in the treatment of acute ankle sprains in the Australian military.
Compared with the placebo group, the subjects treated with Piroxicam had less pain, were able to resume training more rapidly, were treated at lower cost, and were found to have increased exercise endurance upon resumption of activity. At first glance in reviewing this study, NSAIDs appear to be great, but the real question is…did they help the ligament injury heal?
To test ligament healing, the ankles were tested via the anterior drawer test. During this test, the ankle was moved forward to determine the laxity of the ligaments. In this study, at every date of testing after the initial injury, days three, seven, and fourteen, the Piroxicam-treated group demonstrated greater ligament instability.
At the time of the initial injury, the ligament instability in the Piroxicam group and the control group were exactly the same. This study showed that the NSAID stopped ligament healing, yet the person felt better. The authors noted, “This result is of concern in that it may reflect a paradoxically adverse effect of the NSAID-derived analgesia in allowing subjects to resume activity prematurely.”(6)
NSAIDs and the acceleration of the arthritis process
NSAIDs are truly anti-inflammatory in their mechanism of action. Since all tissues heal by inflammation, one can see why long-term use of these medications will have harmful effects. Osteoarthritis and other chronic pain disorders are not an ibuprofen or other NSAID deficiency. Their chronic long-term use will not cure, and will actually hamper soft tissue healing and accelerate the arthritic process.
In my 2010 study that I referenced above, I concluded the research with these thoughts”
The lay public for whom NSAIDs are prescribed and recommended by both healthcare professionals and drug manufacturers should be aware that long-term NSAID use is detrimental to articular cartilage. Specifically, be informed that NSAIDs will likely worsen the osteoarthritis disease for which it is prescribed. Physicians, allied health care professionals, and drug manufacturers should be required to inform the lay public that NSAID use can accelerate osteoarthritis articular cartilage degeneration. A strict warning label on these medications should read as follows:
The use of this nonsteroidal anti-inflammatory medication has been shown in scientific studies to accelerate the articular cartilage breakdown in osteoarthritis. Use of this product poses a significant risk in accelerating osteoarthritis joint breakdown. Anyone using this product for the pain of osteoarthritis should be under a doctor’s care and use of this product should be with the very lowest dose and for the shortest possible duration of time.
One of the basic tenants of medicine is stated in the Hippocratic oath, “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.” For doctors to uphold this statement in the treatment of their osteoarthritis patients, it would necessitate the almost complete banning of the use of NSAIDs for this condition. If this does not occur, then most likely the exponential rise in degenerative arthritis and subsequent musculoskeletal surgeries, including knee and hip replacements, as well as spine surgeries, will continue for decades to come.”
If this article has helped you understand the role of NSAIDs in accelerating you need for joint replacement and would like to explore options to avoid surgery, get help and information from our specialists
1 Allen J, Imbert I, Havelin J, Henderson T, Stevenson G, Liaw L, King T. Effects of treadmill exercise on advanced osteoarthritis pain in rats. Arthritis & Rheumatology. 2017 Jul;69(7):1407-17. [Google Scholar]
2 Goulet JL, Buta E, Brennan M, Heapy A, Fraenkel L. Discontinuing a non-steroidal anti-inflammatory drug (NSAID) in patients with knee osteoarthritis: Design and protocol of a placebo-controlled, noninferiority, randomized withdrawal trial. Contemporary clinical trials. 2018 Feb 28;65:1-7. [Google Scholar]
3 Havelin J, Imbert I, Cormier J, Allen J, Porreca F, King T. Central Sensitization and Neuropathic Features of Ongoing Pain in a Rat Model of Advanced Osteoarthritis. J Pain. 2016 Mar;17(3):374-82. [Google Scholar]
4 Hauser RA. The acceleration of articular cartilage degeneration in osteoarthritis by nonsteroidal anti-inflammatory drugs. Journal of Prolotherapy. 2010;2(1):305-22.
5. Almekinders, L. An in vitro investigation into the effects of repetitive motion and nonsteroidal anti-inflammatory medication on human tendon fibroblasts. American Journal of Sports Medicine. 1995; 23:119-123. [Google Scholar]
6. Slatyer, M. A randomized controlled trial of Piroxicam in the management of acute ankle sprain in Australian regular army recruits. American Journal of Sports Medicine. 1997; 25:544-553. [Google Scholar]