What’s the BEST PAIN relief?

Painkillers should be a short- term proposition, says arun Bhaskar, a consultant in pain medicine at imperial College Healthcare nHs Trust and president of The British Pain society — and even then only as part of a programme designed to get you mobile again.

The drugs typically prescribed for back pain — non- steroidal antiinflammatory drugs (nsaiDs) such as ibuprofen, and prescription- only diclofenac and naproxen — can cause side-effects such as heartburn and even stomach ulcers, while long-term use of opioid drugs, such as codeine, can lead to addiction.

‘if you go to your GP or to a&e with severe back pain, once they have ruled out something nasty, you are likely to be given some simple painkillers and, after a couple of days, you’re on your way,’ says Dr Bhaskar. ‘You have to stay active. We see patients who are capable of walking without any aids, yet they were given a crutch temporarily five years ago and they are still using it.’

long-term, nsaiDs are not good for the stomach lining or the kidneys, and can increase the risk of stroke and heart disease. They also can’t be taken with some other medicines. This is why the national institute for Health and Care excellence (niCe) recommends that the drugs should be given for lower back pain only ‘at the lowest effective dose for the shortest possible period’.

should that fail, ‘then we are talking about opioids’, says Dr Bhaskar. This may begin with weak opioids, such as codeine, possibly combined with paracetamol, available as co-codamol or co-dydramol.

OPioiDscan cause constipation. More serious side- effects include addiction and problems with withdrawal.

Yet some studies have found that opioids are not even as effective for back pain as nsaiDs or paracetamol.

Many patients Dr Bhaskar sees ‘expect their problems to be fixed through medication, injections or surgery, and that belief flies in the face of what we recommend: that people with back pain need to be more active, more mobile, and look after their health’, he says.

‘in fact, studies suggest the incidence of back pain is higher in the desk-bound than people working with heavy objects.’

if you find you aren’t coping well with your pain, ask your GP for a referral to a pain clinic.

Pain specialists have other weapons in their armoury to use against back pain. These include:

Lumbar epidural:

an injection into the epidural space at the back of the spine, through which the spinal cord runs. it combines an anaesthetic to numb pain and corticosteroids to reduce swelling. The injections are approved for severe sciatica, or ‘radicular’ pain — where pain from a trapped nerve radiates down the leg — when other treatments haven’t worked.

The effects can last for up to a few months, during which time, it’s important to keep exercising and working on your core stability to support your spine properly, says Dr Bhaskar.

Medial branch block:

These are diagnostic injections, used to determine whether long-term or recurring back pain is being caused by inflammation, injury or wear and tear — but they can also help pain.

Using X-rays or CT scans for guidance, a combination of local anaesthetic and steroids is injected close to one or more of the small ‘medial branch’ nerves that carry pain messages from the facet joints to the brain. if the patient’s pain disappears, the guilty nerve has been found.

This can also relieve pain for up to three months, and a study in the journal spine in 2008 found that in half of cases this injection eased back pain for good.

Facet joint injection: similar to a medial branch block, except the local anaesthetic and steroid are injected directly into one of the joints.

Radiofrequency denervation:

This treatment can be offered for chronic lower back pain when other treatment hasn’t worked, but a medial branch block has shown the source of pain is most likely to be a facet joint medial branch nerve.

special needles, guided by X-ray, are inserted alongside the nerve. a small electric current is passed through them, creating heat which destroys the ability of the nerve to transmit pain.

studies suggest this works in 60 per cent of cases, lasting for anything from a few months to a few years. niCe recommends it when back pain has lasted for longer than 12 weeks, despite treatment, and the source of pain is thought to be one of the medial branch nerves.