One of the first line of treatment of all spinal disorders is medications. Many years ago only few classes of drugs existed and only few drugs in each class. Recently, we have seen an explosion in the number of newly developed medication. Each drug is different than the other, however, the basic concepts and mechanism of action is the same. Medications are generally considered to be safe and are often used along with other treatment modalities. Even after surgical procedures some patients may still benefit from medications prescribed. Before categorizing the medications it must be emphasized that each medication has two different names. Drugs are first given a scientific or the generic name and secondly given a Brand name which is used by the manufacturing companies for marketing purposes. An example is Acetaminophen (generic name) which is also called Tylenol (brand name). Medications can be categorized in several different ways. We will begin with the issue of prescription vs. over the counter medications. It is a misnomer that prescribed medications are stronger than over the counter medications. The medication Ibuprofen (also called Motrin and Advil) is sold over the counter in the dosage of 200mg per pill. The same drug with higher doses is prescribed in 400mg, 600mg, or 800mg. Patients could simply take 4 over the counter pills which is equal to one 800mg pill which is prescribed by your physician. Furthermore, 800mg of Motrin is much stronger than the prescribed medication Relafen which is a relatively weak Non-Steroidal Anti-inflammatory Drug (NSAID). Before further discussion regarding the different medications it must be emphasized that every drug has risks and benefits of consumption. Every new drug approved by the FDA has slightly different properties as compared to other similar drugs. Along with the common benefits they share many similar side effects and dangers. However, prior to their use the risk vs. benefits should be carefully considered.
The most commonly used class of drugs are the NSAIDs (Non-Steroidal Anti-inflammatory Drug). These medications are the first line of treatment for most spine and orthopedic disorders. They halt the inflammatory cascade and by this action reduce pain and swelling. Since the end result of most conditions include inflammation, these drugs are very helpful in the treatment plan. Examples of these medications include: Aspirin, Motrin (also called Ibuprofen, Advil), Naproxen (also called Naprosyn or Aleve), Relafen, Feldene, Lodine, Daypro, etc.. The list of these NSAIDs is long and includes about 50 different medications. Each medication is slightly different than the other but their basic action is the same. Common to all of these medications is the danger of stomach ulcers and bleeding. They may also cause stomach irritation and pain. If patients utilize one of these medications longer than a few weeks blood tests will be performed to monitor kidney and liver function periodically. It is probably a good idea to monitor these two organs whenever patients remain on a medication for longer periods. To reduce the rate of stomach problems, few years ago a drug by the name of Cytotec was introduced into the market. This is a Prostoglandin medication which has protective effects on the stomach. The drug Arthrotec is a mixture of two drugs, one is an NSAID and the other is Cytotec. The combination has been shown to have decreased incidence of stomach ulcers. Patients taking the drug Cytotec should realize that this drug will cause diarrhea or loose stools. This problem is encountered only during the first week of therapy and eases off slowly. Most recently, a new class of drugs was introduced in the market. These include the COX-2 inhibitors with the brand names of Celebrex and Vioxx. They now dominate the market and are widely prescribed. Even though the reported rates of bleeding ulcers are lower, they may still cause these complications in the predisposed patients. Patients allergic to Sulfa drugs should avoid Celebrex and patients with high blood pressure and leg swelling may experience worsening of these problems with Vioxx. It should also be remembered that the later two drugs have no reported effects on platelet function and provide no cardiovascular benefit as described for other NSAIDs like Aspirin. For this reason patients taking blood thinner are more appropriately treated with Celebrex or Vioxx as opposed to Motrin or Naprosyn.
The second type of drugs used is the Steroidal medications. These are the most powerful anti-inflammatory medications and also have more sever side affects. Example of these is Solumedrol, Kenolog, and Celestone. The major side affect of these medications is the relatively high rate of stomach irritation and production of ulcers. Their use for short periods is very effective with relatively low rates of complications and side effects. Some patients remain on these drugs on a long term basis and they should be monitored closely by their primary care physician. Many side effects are described and their risks vs. benefits should be compared with usage. Other side effects are uncommon but still described. These complications are usually seen with more extended periods of use and include but not limited to osteoporosis, avascular necrosis of femoral head (death of the bone in the hip joint), and weight gain. The Medrol Dose pack is commonly prescribed which is taken orally. The first day higher doses are taken and it is gradually decreased over 5 days. Usually, relief is experienced after 2 or 3 days of use. Dramatic pain reduction could be observed with return of sensory and motor function if these were problematic before. Patients usually describe a sense of well being since many of the commonly felt aches and pains resolve with these medications. Steroidal medications could dramatically reduce the pain of a herniated disc.
Narcotic medications are also very important weapon in the treatment of back conditions. Since the pain intensity of such disorders could be very intense, narcotic medications are often used in our patient population. These medications have similar effect to Heroin but are milder in strength. In general, the stronger the effects of the medications, the more sever its side effects. They must be used for short periods when pain is most intense and replaced with less addictive alternatives. The list of narcotic medications and the different preparations are long, but most work with the same mechanism of actions. They work in the central nervous system to decrease the perception of pain and are most effective if used for short periods. The human body has a tendency to develop tolerance for these medications, and eventually much higher dosage of the drug is needed to produce the same effect. Patients with chronic pain commonly need much higher doses of these medications to achieve adequate pain relief. Some patients that finally resort to operative treatment after long periods of narcotics usage utilize great amounts of medication in the operating room for the purposes of anesthesia. Narcotics have unique side effect of their own. Since these medications slow down the motility of the intestines, patients experience constipation. Addiction is another dreaded complication and should be avoided to prevent complications of the spinal disorder. Patients taking these medications should not be driving or operate other machinery since they cause drowsiness, impair judgment, and slow down reflexes. Examples of these medications include, Vicodin, Vicoprofen, Darvocet, Tylenol #2, #3, #4, Percocet, and OxyContin.
Muscle relaxants are a group of drugs which have a sedative effect on the body. Even though their mechanism of actions is still not completely understood, we know that they don’t work on the muscles directly. They act on the brain to cause drowsiness and in turn relax muscles indirectly. Many patients report a beneficial effect from these medications, but research has shown no real benefit from these drugs. At best these drugs should only be used for short periods during the acute period of the illness. There are several muscle relaxants for prescription and they include Soma (Carisoprodol) which is 350mg per pill taken every eight hours as needed. These drugs, like the narcotics could be addictive and caution should be exercised in their use. Flexoril is a different type and can be used for longer periods. Its dosage is 10mg at night but it may cause urinary retention in patients with prostate problems. Skelaxin is a mild muscle relaxant and is prescribed for athletes to avoid the sedative effects of these drugs. Another strong muscle relaxant is Valium. This drug is used post operatively to reduce muscle spasm in the surgical site.
Anti-Seizure medications, or the so called Neuroleptic drugs. These medications are prescribed to reduce nerve pain (radiculopathy) or nerve degeneration (neuropathy). These conditions are seen with herniated discs and in diabetic patients. They help stabilize the cell membrane and reduce the perceived pain. These medications can be used on a long term basis and are relatively well tolerated. These medications include the commonly prescribed Neurontin. Some patients may complain of nausea, fatigue, drowsiness, and dizziness.
Antidepressant medications can also be helpful to reduce pain and decrease nerve pain. Their exact mechanism of action is still unknown in regards to pain reduction but they can be used on a long term basis. They are not addictive and patients may gain a two fold benefit by eliminating depression and decreasing nerve and back pain. These medications also cause drowsiness and can help the patient sleep more comfortably. Examples include Elavil, Amytriptiline, Nortriptiline, and Imipranime. Elavil is most commonly used and is safe to use. It should not be taken with any other psychiatric medications and alcohol should be avoided while taking this medications. It is also important to note that these medications should not be stopped abruptly but should be weaned off slowly.
Centrally acting pain medications are taken orally and work on the brain to decrease the perception of pain. They do not decrease inflammation or help the healing process but are very effective to decrease pain. They are only mildly addictive and can be used on long term basis since patients do not develop tolerance to the medication. The drug in this category is Ultram and is prescribed in the dosage of 50mg every 4 to 6 hours as needed for pain. Patients with history of seizures should avoid taking this medication since it may increase the likelihood of seizures in predisposed patients. Ultram should not be taken with other medication such as anti-depressants, alcohol, and narcotics. The effect of Ultram is very variable in regard to pain control. Some patients gain major pain relief from these medications while others report no effect at all. For this reason we begin this medication on a trial basis and if it works for the patient we continue its use. It is ideal in patients with history of stomach ulcers or heart burn since it has no effect on the lining of stomach.
Medications to increase bone density and Osteoporosis. Osteoporosis refers to thinning of bones which is seen in elderly women and men. The reduction of bone density begins after the age of 35 but its effects are only noticed later on in life. Recently the DEXA scan which measures bone density has become widely available and its use is increasing. The best treatment of this condition is prevention, however, its prevention must begin early in life at the age of 20. The body begins building and increasing bone density up to the age of 35 and from that time we loose our stores slowly every year. Supplements of calcium and Vit. D are commonly used to treat this condition. Patients must know that this treatment regime does not increase bone density in the elderly patient. This regime only slows down the decrease of bone density. Newer drugs introduced to the market include Fosamax. This drug decreases the natural turnover of bone and also increases bone mass. This increase in bone mass is not very large but still significant. Fosomax is associated with side effects most significantly Heart burn and esophageal (tube that carries food down to the stomach) irritation. Patients should take this medication with plenty of water and should avoid laying down for 30 minutes after taking the medication. Calcitonin is another drug used but is less effective than Fosomax. Calcitonin is a hormone that is naturally produced by the body. Its normal action is to stop the calcium in our bones from breaking up and entering the blood stream. It is available in a convenient nasal spray.
- Arthrotec – 75mg – One tab twice a day
- Naprosyn – 250, 500mg – One tab two or three times a day with meals
- EC Naprosyn – 500mg – One tab two time a day
- Voltaren – 75mg – One tab two time a day
- Voltaren XR – 100mg – One tab a day
- Indocin SR – 75mg – One tab a day
- Feldene – 20mg – One tab once a day
- Clinoril – 200mg – One tab twice a day
- Disalcid – 750mg – One tab once a day
- Motrin (also known as Advil, Ibuprofen) – 400,600,800 – One tab three time a day with meals
- Anaprox – 550mg – One tab twice a day
- Tolectin – 400mg – One tab twice a day
- Nalfon – 200mg – One tab twice a day
- Aspirin – 325mg – One tab once or twice a day
- Orudis – 75mg – One tab twice a day
- Dolobid – 500mg – One tab twice a day
- Ansaid – 100mg – One tab twice a day
- Lodine – 200,300,500 – One tab twice a day
- Lodine XL – 400mg – Two tabs once a day
- Daypro – 600mg – Two tabs once a day
- Oruvail – 200mg – One tab once a day
- Cataflam – 50mg – One tab once a day
- Toradol – 10mg – One tab three time a day (use only 5 days)
- Relafen – 500,750mg – One tablet twice a day
- Indocin – 25,50mg – One tab once a day
- Indocin – 25mg – One tab twice a day
- Meclomen – 100mg – One tab twice a day
- Trilisate – 500, 750mg – One tab twice a day
- Naprelan – 500mg – Two tabs once a day
- Celebrex – 100, 200mg – One tab once a day (not approved twice a day but commonly used.)
- Vioxx – 25, 50mg – One tab once a day
- Valium – 2, 5, 10mg – One tab once or twice a day. 10mg for sever anxiety.
- Robaxin – 750mg – One tab three time a day
- Flexeril – 10mg – One tab three time a day or before sleeping
- Soma – 350mg – One tab three time a day or as needed for spasm
- Parafen – Forte – One three time a day as needed
- Parafen – Forte dsc – One three time a day as needed
- Ativan – 0.5, 1, 2mg – As needed
- Skelaxin – 800mg – Two tabs three time a day
Pain Medications (Narcotics except Ultram)
- Vicodin – One tab every 4-6 hours as needed for pain
- Vicodin – ES, HP – One tab every 4-6 hours as needed for pain
- Vicoprofen – One tab every 6 hours as needed for pain
- Tylenol – #3, #4 – One tab every 4-6 hours as needed for pain
- Ultram – 50mg – One tablet every 6 hours
- Darvocet – N100 – One tab every 4-6 hours as needed for pain
- Percocet – One tab every 4-6 hours as needed for pain
- Demerol – 50mg – One tab every 4-6 hours as needed for pain
- Fioricet – One tab every 4-6 hours as needed for pain
- OxyContin – Variety – Variety
Nerve Stabilizers (neuroleptics)
- Elavil – 25mg – One tab three time a day or before sleeping (also an anti-depressant)
- Neurontin – 100mg – One tab on day1, two tabs on day 2, three tabs every day from third day on.
- Ambiem – 10mg – One tab before sleeping
- Restoril – 30mg – One tab before sleeping
- Dalmaine – 30mg – One tab before sleeping
- Benadryl – 50mg – One tab before sleeping
- Zantac – 150mg – One tab twice a day
- Tagamet – 300mg – One tab twice a day
- Cytotec – 100mcg – one tab twice a day (an ingredient already mixed in Arthrotec)
- Prilosec – 20mg – One tab once a day