Out of control - nsaids and you

About to pop a pill for a headache? Think again, you could be doing yourself untold damage

Along with a basic first aid kit, the common medicine found in any household medicine cupboard is probably a pain reliever. From paracetamol to any nonsteroidal anti-inflammatory drug - nsaid for short - an over-the-counter pain reliever is used by just about everyone to ease everything from a headache to a migraine to back pain and osteoarthritis. Recently, the first Asian survey on self-medication for chronic pain revealed that about 60 per cent of chronic pain sufferers self medicate, swallowing drugs without ever consulting a physician. Sponsored by Pfizer, the online survey of 1,220 chronic pain patients in China, Taiwan and Thailand aimed to understand chronic pain in the region. "The result is predictable but the good thing is that it's the first time that we've conducted a survey about the problem," says Professor Udom Kachintorn, chairman of the department of Internal Medicine at the Faculty of Medicine, Siriraj Hospital. The survey shows that Taiwanese and Chinese suffer chronic pain for years while in Thai patients, the period before medical consultation tends to be shorter, usually from six months to one year. The most common chronic pains are migraines and headaches, which ranked highest in China and Taiwan. In Thailand, people complained of back pain slightly more than migraine. The reason given for not seeing a doctor to seek relief is "the pain is manageable". While it is safe to take nsaids to relieve pain, they should only be take once in a while and never on a regular basis. Those who take nsaids for chronic pain frequently and over a long period are likely to suffer from complications in the long run, starting from stomach ache to ulcers to bleeding in the abdomen and possibly even a heart attack. Nsaids work by blocking the effects of enzymes that are involved in protecting the stomach lining from corrosive acid and inflammation. Too many nsaids for too long and the drugs will interfere the stomach's ability to protect itself from acidic juices. Illnesses caused by the drugs are often found in elderly people because joints deteriorate as we age and nsaids are taken daily to relieve knee and hip pain. In the past, the bleeding caused by taking nsaids was thought to be limited to the upper gastrointestinal tract, particularly the stomach, as when bleeding occurs, patients usually complained of significant stomach pain. However, recently bleeding has also been found in the lower digestive part, including the six-metre-long small intestine and the large intestine. "Bleeding in the small intestines is difficult to diagnose, because it's long and the bleeding is too little to cause pain. But it can be severe especially if it continues for a long period and leads to a perforation. That's when heavy bleeding starts and a patient's life can be at risk," says Dr Udom. "Many patients develop GI complications and there are no warning symptoms. So it's a misconception that as long as they are no stomach symptoms, everything is fine," says Profesoor Francis Ka-leung Chan, chief of Gastroenterology and Hepatology at the Chinese University of Hong Kong. Chan ran a randomised trial on the different effects on the GI tract of drugs containing celcoxib (the active ingredient in Celebrex, used in the treatment of osteoarthritis) versus diclofenac (the main ingredient in Voltaren), which is often taken with omeprazole, a drug used for treating acid-induced inflammation. Dr Udom says that even the common advice that eating before taking nsaids to prevent stomach irritation doesn't help alleviate side effects because the nsaids still affect the GI tract. "More than 50 per cent of patients who have bleeding in the GI tract have a record of taking nsaids," he says. Another danger is mixing drugs - a wrong combination can lead to a heart attack. Take an instance where a patient with a heart problem consults a doctor for knee pain. When the doctor gives a prescription for an nsaid, the side effects can be severe. "Whenever you go to see the doctor, you must be clear about the medications you are taking and that includes all over-the-counter drugs. The doctor should have a detailed record before writing any prescription. Don't be scared of the doctor, it's your right to know and ask questions," says Dr Udom. In Thailand, patients often are afraid of the doctor and don't feel they can ask about their symptoms or treatment. By the same token, doctors are often too busy or unwilling to explain too much to patients. He's also concerned that nsaids continue to be so easily bought over the counter without prescription. "Nsaids are among the top five best selling drugs in this country. The others are medications for diabetes and hypertension," says Dr Udom. Dr Yeo, who conducted the survey, adds that anyone taking nsaids should have a blood test every six months or once a year at the outside to check on kidney and liver function. "It's the preliminary process to see what's wrong with your body. In general, if you are taking nsaids and you still have pain after two to four weeks, you should see a doctor," he says. Alternative medication is also an option. Dr Yeo says that many alternative treatments can cure pain, such as an injection to the spine for chronic back pain. "But the best way is the preventive approach. If you have migraines regularly, taking preventive medicine can avoid the effects of taking nsaids. Exercise or changing your posture more often can help prevent back or neck pain. It's the best medication for everyone," says Dr Yeo.