4. Acetaminophen

Other measures which could be employed to reduce pain, with little to no risk to the patient, include the use of steroid injections for musculoskeletal pain, physical therapy, massage,

NSAIDs are generally considered non-specific analgesic medications and these are commonly prescribed for inflammation-derived acute pain. This class of drugs acts mainly through the inhibition COX (cyclooxygenase) synthesis, this then leads to a decreased in the synthesis of prostaglandin [35]. Being widely diffused, NSAIDs are often used in combination with further on-going treatments, leading to final effects dependent on drug-drug interactions [1]. However, prescribers should take into account the intrinsic risk of NSAIDs' ADRs (Table 2).

Complications involving the gastrointestinal tract as a consequence of NSAID use are common, especially in combination with the presence of risk factors [36]. NSAIDs exert their effects through the inhibition of COX and the pharmacological inhibition of COX (both 1 and 2

This NSAID-induced decrease in prostaglandin synthesis is responsible for side effects such as dyspepsia, abdominal pain, nausea, vomiting, heartburn, haemorrhage (NSAIDs could also lead to prolongation of bleeding time and a significantly increased risk of haemorrhage by altering vascular homeostasis), ulceration, perforation or obstruction [37].Therefore, COX-2 specific inhibitors, for example celecoxib, have a lower risk of causing gastrointestinal related

NSAIDs are also a cause of renal complications. Acute renal failure is a possible consequence of NSAID use. While this is an intrinsic risk of NSAID medications, it is more likely to occur in geriatric patients and in patients using enzyme inhibitors (ACEIs) or angiotensin receptor II blockers [39]. NSAIDs are the class of medicines that are most commonly associated with hypersensitivity reactions. Because of this, it is generally not recommended to use NSAIDs even after having an unrelated hypersensitivity reaction or having positive allergy tests. NSAID-triggered hypersensitivity reactions can result in respiratory complications or in der-

isoenzymes) works to provide relief from the symptoms of inflammation and pain.

Table 2. The intrinsic risk of ADRs associated with NSAIDs [7, 40].

exercise and chiropractic care [34].

174 Pain Relief - From Analgesics to Alternative Therapies

3. NSAIDs

1. Gastrointestinal bleeding 2. Cardiovascular disease

4. Thrombotic disease 5. Arrhythmia

3. Stroke

ADRs [38].

matological problems [40, 41].

Acetaminophen is often used as the first-line treatment for pain relief for many diagnoses across the fields of medicine, globally. As an over the counter medication, it is either prescribed by a doctor or bought by patients. The patients either complete the course as directed or they continue buying and self-treat with the medication, managing the doses on their own and subsequently increasing the dose with increasing pain. This behaviour, which is encouraged by some physicians, can be fatal and has been proven to be useless in most cases of long-term chronic pain management [46].

It is now known that acetaminophen is not effective in substantially reducing chronic pain conditions such as osteoarthritis, back pain or post-operative pain [47, 48]. A careful, systematic and thorough review of acetaminophen use becoming a public health and ethical concern must be gauged in depth across the globe. When one considers the ADRs associated with its use, acetaminophen as a first-line treatment for chronic pain seems to call for further evaluation; ADRs such as liver failure can occur in any patient demographic regardless of pre-existing conditions ranging from abnormal liver enzyme profiles to requiring liver transplantation.

Of note, hepatotoxicity is considered when more than 4 gm of acetaminophen have been administered in 1 day [49], but there have been cases of liver injury occurring even at lower doses [50]; geared with this information, physicians should begin to re-evaluate their stance on acetaminophen being completely safe for use with patients at home, regardless of their liver health status and especially in the setting of long-term chronic pain management.
