Writing and Researching: When Painkillers Make Back Pain Worse

Are you feeling that familiar twinge in your back? You’re not alone. Chronic pain affects an estimated 50 million adults in the United States, with injury being the most common cause.¹ A quarter of US adults report having lower back pain in the last three months.²

If you have been dealing with lower back pain, your doctor may have advised you to take painkillers to ease the pain. But new research has suggested that popping a painkiller might worsen acute pain and make it last longer, turning it into chronic pain.

If medication is off the menu, what can you do if you have a backache, and how does this research impact the future of medicine? Let’s find out more.

Our backs are impressive powerhouses, but that means they take most of the strain of our everyday activities. Lower back pain is the leading cause of disability and the second most common reason people visit their doctor worldwide.³ ⁴

Lower back pain is the most significant cause of time off work and reduced activities, resulting in a vast economic and medical burden. Around 80% of people will experience lower back pain at some point in their lives.⁵

In around 20% of people, short-term, acute pain can turn into chronic pain.⁶

While long-standing medical advice might be to pop a non-steroidal anti-inflammatory drug (NSAID) to handle your back pain, new research from McGill University shows this may lead to chronic pain. The researchers suggest that inflammation in the body exists for a reason, and when we take medications to stop this response, it has negative effects.

Inflammation is a reaction to infection and injury where your immune system sends out cytokines and inflammatory cells. These stimulate more inflammatory cells to trap threats such as bacteria and begin healing damaged tissue. This is when you notice symptoms of acute inflammation, such as redness, swelling, bruising, or pain. As inflammation increases, you may feel more pain.⁷

Chronic inflammation is where your body creates inflammatory cells when there’s no danger. This is a hallmark of autoimmune conditions like rheumatoid arthritis. With autoimmune disorders, your body attacks healthy cells and causes damage.

While inflammation can be painful and irritating, blocking it may cause chronic, long-term consequences. A 2012 study noted several reasons wounds heal slower, and one of those was NSAIDs. But how does blocking inflammation turn acute pain into chronic pain?⁸

While some people recover from acute pain, others deal with chronic pain. The researchers of the 2022 study were looking to understand the transition from acute to chronic pain.⁹

They studied 98 patients with lower back pain over three months and noted that a certain immune system cell played a huge role: neutrophils. These are a type of white blood cells that help your body fight infection.

Neutrophils are key in the pain response pathway, so blocking these cells reduces pain in the short term. However, when researchers blocked neutrophils in mice, it prolonged the pain for up to ten times longer. They discovered that people without pain medication had high levels of neutrophils and a protective factor against chronic pain.

The researchers also used data from the UK Biobank, which holds information about 500,000 patients’ medical conditions and medication use. They selected the data of 2,163 people with acute back pain, of whom 461 developed chronic pain. They discovered patients regularly taking NSAIDs were almost twice as likely to develop chronic back pain as those who did not.

Knowledge about NSAIDs affecting neutrophils isn’t new. A 1993 study focused on the link between NSAIDs and neutropenia, a condition where neutrophil levels are low.¹⁰ The researchers confirmed that NSAIDs were associated with neutropenia. A 2013 case study noted a link between ibuprofen and neutropenia, commenting that the condition has an incidence rate of less than 1% as a side effect.¹¹

It’s often an easier option to pop a pill to try and forget that ache in your back. Unfortunately, painkillers tend to mask the problem. This means you’re not dealing with the underlying issue. You also expose yourself to side effects when the medication might not even ease your pain.

Scientists estimate that around 30 million people worldwide use NSAIDs every day for their pain-relieving and anti-inflammatory properties. They can also prevent blood clots and decrease fever. It’s common to reach for an anti-inflammatory when you have headaches, cold symptoms, painful periods, muscle strains, and arthritic pain.¹²

Naproxen

Ibuprofen

High-dose aspirin (300mg or more)

Celecoxib

Diclofenac

Mefenamic acid

Indomethacin

Etoricoxib

A 2016 analysis of randomized clinical trials discovered that NSAIDs have almost no benefit over placebos in reducing lower back pain. So, why do we keep using them?¹³

As anti-inflammatories reduce inflammation, it decreases swelling and impacts your body, so you’ll feel less pain. Still, NSAIDs have risks and may not be suitable for you if you have other conditions. Possible side effects include:

Stomach ulcers, which can cause internal bleeding

Indigestion, including stomach aches, nausea, and diarrhea

Drowsiness

Dizziness

Headaches

In rare cases:

While paracetamol (acetaminophen) isn’t an NSAID, it still has its problems. It’s the most-purchased over-the-counter painkiller, and healthcare providers often recommend it for pain relief. However, a 2015 study revealed that paracetamol doesn’t ease back pain.¹⁴

Paracetamol builds up in your body, risking liver damage and overdose. So, you risk overdose even if you only take a couple of tablets over the recommended daily maximum of 4,000mg. It’s critical to check the active ingredients in other medications; certain drugs can contain paracetamol, including cold and flu medications, Vicodin, and even aspirin-based drugs.

In 2011, the US Food and Drug Administration (FDA) issued a safety communication for acetaminophen. It requested that companies producing prescription drugs limit the amount of acetaminophen to 325mg per tablet to improve safety. It also enforced the need for a boxed warning highlighting the risk of severe liver injury and allergic reactions.¹⁵

Opioids are a last resort for treating lower back pain as they can lead to addiction, and they don’t treat the underlying problem. These drugs decrease your brain’s reaction to pain by affecting opioid receptors on your nerve cells.

Examples of opioids include:

Morphine

Fentanyl

Codeine

Oxycodone

Hydrocodone

Generally, around 20% of patients on long-term opioid therapy develop a dependence or addiction.¹⁶ The disorder arises in 5%–25% of lower back pain patients on opioids.¹⁷ So, are opioids worth the risk?

While opioids may temporarily ease your back pain, the risk of opioid use disorder is high. They can cause physical dependence within as little as four to eight weeks. This dependence leads to nasty withdrawal symptoms, especially if you’ve taken too many doses too often.

If you’re dependent on opioids, you’re likely to keep taking them to avoid severe withdrawal, so there’s no motivation to stop. People who are addicted to opioids are 40 times more likely to become addicted to heroin, according to the Centers for Disease Control (CDC).¹⁸

Addiction isn’t the only issue that opioids can cause. While you may expect opioids to ease your pain, opioid-induced hyperalgesia (OIH) is a paradoxical side effect where your pain sensitivity increases. Scientists first described the condition in 1943, noting a decreased pain tolerance or threshold.¹⁹

Your pain tolerance is how much pain you can take before seeking relief, and your pain threshold is how long it takes for you to feel pain. So, with OIH, you could end up in more pain than before you started taking opioids.

While researchers haven’t pinpointed the exact reason for OIH, leading theories involve changes to the brain’s neuroplasticity and pain receptors.²⁰

Given the risk of addiction and hyperalgesia, requesting a non-opioid painkiller for your back pain and investigating other options may be the best course of action.

The American Academy of Family Physicians suggests treating pain with heat, massage, or physical therapy over medication. If these don’t work, you may need to take painkillers, but it’s best to ask your doctor for their advice.²¹

Here are several things you can try before reaching for a painkiller.

While movement may be the last thing you want to do with a sore back, studies have consistently shown that bed rest delays recovery.²² Continuing your daily activities is essential, and gentle exercise such as walking or swimming can be beneficial. Aerobic exercise generates endorphins, a natural painkiller.

Core stabilization and strengthening exercises can reduce lower back pain by up to 76.8%.²³ It may be best to search for a physical therapist in your area if you’re worried about making your back pain worse.

Working with a licensed professional ensures that any exercise you’re doing is suitable for your body. According to a 2016 study, evidence-based physical therapy can speed up lower back pain recovery.²⁴

Your physical therapist will create a regimen to build your core strength, which includes your back and abdominal muscles. They may also work on your hip flexibility, as tight hip flexors from excessive sitting can cause lower back pain. Strength training and conditioning your body is an excellent way to future-proof against injury.

Most of us spend a lot of time hunched over phones and other devices, so it’s easy to forget the importance of good posture. Be mindful of your posture when sitting and standing.

When standing:

Stand up straight

Pull your shoulders back

Pull your stomach in

Distribute your weight evenly, keeping your weight mainly on the balls of your feet

Keep your head level, don’t crane your neck

Your arms should hang down normally by your sides

Keep your feet comfortably around shoulder-width apart

When sitting:

Keep your feet flat, whether resting them on a footrest or the floor

Don’t cross your ankles or knees

Maintain a small gap between the back of your knees and the chair

Position your knees at the same height or slightly lower than your hips

Place your ankles in front of your knees

Relax your shoulders, but don’t slouch

Keep your forearms and knees parallel to the floor—they should be at right angles

Sit up straight and look forward, but be careful not to strain your neck

Your chair should be comfortable and supportive. If your back doesn’t touch the chair in some areas, using a cushion or backrest can be helpful, especially for the lower back.

Don’t spend too much time sitting; take regular breaks if you need to sit for long periods. A ten-minute break for every hour of sitting is a great way to keep your posture, hip flexors, and lower back in check.

If you’re overweight, your extra weight strains your whole body, including your lower back. A 2021 study discovered that weight gain in people over 50 significantly increased their risk of chronic lower back pain.²⁵ If you believe you could benefit from losing weight, speak to your healthcare provider to work out the best course of action.

We’ve all seen invalidating and unhelpful advice about reducing stress levels. While it’s easier said than done, managing stress can relieve tension in your muscles, including your lower back. A 2021 study found the severity of stress was associated with a 2.8-fold increased risk of chronic lower back pain compared to the general population.²⁶

As stress arises from everything from relationships to work, it can be hard to manage your stressors. Taking time for yourself to do things you enjoy can be invigorating, and it’s always a good idea to reach out to a therapist if you feel like things are too much to handle.

They’ll help you work out coping mechanisms you can use daily and improve your psychological resilience. It’s never shameful to ask for support.

As you know, endorphins from exercise benefit your pain levels, but they can also reduce your stress levels. Exercise also reduces stress hormones like adrenaline and cortisol.

Music can also positively impact your stress levels and your emotional state. Creating a new exercise regimen might positively impact your back pain, stress levels, and fitness—just don’t forget your favorite music!

With 80% of people experiencing lower back pain at some point in their lives, it’s important to understand how to take care of it effectively.⁵ With new research indicating the issues with painkillers, we need to take a different approach to manage lower back pain.

Staying active, engaging in strength training, and holistically approaching your lifestyle can be great ways to get on top of back pain before reaching for painkillers.

If you’ve tried these tips and your back pain isn’t easing, speak to your doctor for a diagnosis. They may request MRIs and other tests to see what’s happening. Regardless of the cause, you’re far from alone if you’re dealing with back pain.

Prevalence of disabilities and associated health conditions among adults --- United States, 1999 | Centers for Disease Control and Prevention (CDC)

Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials (2015)

FDA drug safety communication: Prescription acetaminophen products to be limited to 325 mg per dosage unit; boxed warning will highlight potential for severe liver failure | U.S. Food & Drug Administration

Opioid therapy for chronic low back pain: prescribing considerations for advanced practice registered nurses (2014)

A systematic review of the effects of exercise and physical activity on non-specific chronic low back pain (2016)

The influence of physical therapy guideline adherence on healthcare utilization and costs among patients with low back pain: A systematic review of the literature (2016)

The relationship between change of weight and chronic low back pain in population over 50 years of age: A nationwide cross-sectional study (2021)

The influence of stretching the hip flexor muscles on performance parameters. A systematic review with meta-analysis (2021)

Effects of prolonged sitting with slumped posture on trunk muscular fatigue in adolescents with and without chronic lower back pain (2021)

Is it me or the music? Stress reduction and the role of regulation strategies and music (2019)