Prescription of nonsteroidal anti-inflammatory drugs and muscle relaxants for back pain in the United States.

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Nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants are the most widely prescribed medications for the treatment of back pain. Despite the relatively high frequency with which they are prescribed, only a limited number of studies have analyzed the prescription of these two medications in the United States. The purpose of this study was to investigate national prescription patterns of NSAIDs and muscle relaxants among individuals with back pain in the United States using the 2000 Medical Expenditure Panel Survey (MEPS). Specifically, the authors explored the frequency with which overall and individual types of NSAIDs or muscle relaxants were prescribed, regional variations in the prescription of NSAIDs or muscle relaxants, and patient characteristics associated with the prescription of the two groups.

A total of 23,839 survey respondents, who were a representative sample of the civilian noninstitutionalized population, participated in the 2000 MEPS. The study population was comprised of individuals who were at least 18 years old and who reported experiencing pain in the spine areas. Information regarding the prescription of NSAIDs or muscle relaxants among individuals with back pain was obtained from the prescribed medicine event files in the MEPS.

NSAIDs were divided into two categories: traditional NSAIDs and COX-2 inhibitors. The number of prescriptions for each of these medications was calculated as a percentage of total prescriptions for back pain. The factors investigated in the study such as race, education, family income, health insurance status, and geographic regions were correlated.

Approximately 24.5 million adults reported back pain in 2000. The average age of this patient population was 48 years. About 54% were female and approximately 80% obtained 12th grade or higher levels of education. Most of the individuals with back pain were married (60%) and white (88%). The most frequent diagnosis was ICD 724, which includes spinal stenosis, lumbago, sciatica, and other unspecified back disorders. A total of 44 million prescriptions were dispensed for back pain in 2000. Traditional NSAIDs and COX-2 inhibitors accounted for 16.3% and 10%, respectively. Approximately 18.5% of the prescriptions were for muscle relaxants. A small number of individual drugs accounted for most of the prescriptions for traditional NSAIDs and muscle relaxants. Among individual categories of traditional NSAIDs, ibuprofen and naproxen accounted for approximately 60% of total prescriptions. About 67% of the prescriptions for muscle relaxants were attributed to only three drugs (cyclobenzaprine, carisoprodol, and methocarbamol).

The study found at the national level that there were regional variations in the prescription of COX-2 inhibitors or muscle relaxants, and individual characteristics including age, race and education level were associated with the prescription of some of the medications. Variations in the prescription across different regions and among individuals with different race and educational levels suggest more research is needed to understand the source of the variations and what constitutes optimal prescribing. Head-to-head comparisons of the relative costs and effectiveness among the different categories of the medications should be warranted. Since a small number of individual drugs were attributable to most of the prescription for traditional NSAIDs or muscle relaxants, among individuals with back pain, future studies should focus on comparing relative costs and effectiveness of these most commonly prescribed drugs.

Over the ages there have been many different remedies to treat headache. Recently, different medications have been used with success, however, often these medications can be used improperly and actually exacerbate headaches. The author suggests that physicians can take steps to protect headache patients from misuse of medications. In this section, described as the "Misuse of Analgesics," the author states that patients may take medications too frequently or in excessive amounts, which may decrease therapeutic efficacy. If this occurs, a cycle of increased consumption secondary to increased pain may occur and it may appear that the analgesics not only do not cause a decrease in headaches, but may actually intensify the headache. This paradoxical effect is called rebound headache. There is an important difference between the frequency patients use medications and the quantity that they take. Frequency is more problematic than quantity. There are many factors which may aggravate headaches. In patients suffering from migraines, their headaches may worsen with consumption of caffeine and gastric stasis, which slows the absorption of oral medications--these factors may promote excessive analgesic use in these patients. In patients with muscle contraction headaches, misuse of analgesics is associated with anxiety, depression, and, again, increases in caffeine use. Patients suffering from cluster headaches may take medications early in the cluster attack to help shorten the episode. The consumption of alcohol and the failure to implement prophylactic therapy may also increase analgesic requirements in these patients. Improper use of analgesics is also likely when patients are taking a therapeutic regimen that does not satisfy them. Inappropriately diagnosed headaches will obviously not respond to the wrong analgesics. An accurate diagnosis is essential for effective management of headache. Headache therapy may also fail because the physician does not realize that prophylactic medications are needed. There are guidelines for prescribing analgesics. It is important to select the medication that is appropriate for the degree of pain that the patient has and for the frequency of attacks. Obviously, a dose of ibuprofen of 200 mg will not help a severe incapacitating migraine. However, on the other hand, a mild muscle contraction headache may respond quite favorably to the same regimen. It is also important to make sure that the patient can tolerate the medication that is selected. Also, prescriptions for analgesics should be in limited quantities with few or no refills. Excessive amounts of analgesics, when available, may tempt the patient to take these medications unnecessarily. Many patients may be fearful that any sensation in their head might be a prodrome for a headache and might take medications inappropriately. Patient education is very important. This involves not only explaining side effects of the medications, but also having the patient understand when and how medications should be used. Specific limitations and when not to take the medications are also appropriate. Patients with a history of drug abuse should have limitations on their prescription medications. Migraine headache patients tend to have a low risk for addiction. Cluster headache patients have a low to moderate risk of addiction. Tension-type headache patients tend to have the highest risk of drug addiction. It is important to schedule regular follow-up visits for these patients. Continuity of care will ensure that your treatment plans are adhered to. There are many different types of medications that can be used for the symptomatic relief of headaches. It is best to progress methodically through the various levels of therapy and increase potency along the way. Non-steroidal anti-inflammatory drugs (NSAIDs) can be used quite effectively. The author states that naproxen sodium and ibuprofen are extremely effective. The author also states that he frequently uses diflunisal, indomethacin, ketoprofen, and meclofenamate. Muscle relaxants can be used to treat headaches that are not severe. The author often uses carisoprodol (Soma) as well as metaxalone (Skelaxin). Analgesics can also be used, such as pentazocine and propoxyphene. Other medications not often thought of as analgesics include chlorpromazine, diphenhydramine, hydroxyzine, and promethazine. Symptomatic treatment for headaches is discussed. For patients suffering from migraine headaches, the NSAIDs are quite effective. Muscle relaxants can be used occasionally. The author states a combination of analgesics are usually quite effective. Some patients may have good results with phenothiazines and antihistamines. Only in a minority of patients are narcotics appropriate therapy. In patients suffering from tension-type headache, NSAIDs are quite effective. Muscle relaxants can also be quite effective. Combination analgesics can be used for resisting cases. Antihistamines and phenothiazines may also be effective. Mixed headaches are also discussed, and these patients may have a high abuse potential; NSAIDs and muscle relaxants may be helpful. Antihistamines and phenothiazines, again, will help, especially in those patients with a history of addiction. Narcotics should not be used in patients with mixed headaches. Episodic cluster headaches should be treated with preventive medicine if possible. O2 therapy can be used for symptomatic treatment in patients with episodic cluster headaches. Also, drops of 4% lidocaine solution can be used. Combination analgesics and phenothiazines can be helpful as well. Narcotics are also an option, but it is important to be careful because of the addiction potential. The author concludes suggesting that, when taken properly, analgesics provide safe and effective symptomatic therapy for headaches. It is the physician's responsibility to ensure that patients use analgesics appropriately. It is important for the physicians to help protect their patients and to have them use their medications in a comprehensive treatment program.