By Medi-Share member and guest blogger Dr. Chad Prodromos
The “No Pills - No Pain” Injury/Chronic Pain Treatment Paradigm
What Does “No Pills, No Pain” Mean?
It is the name of a paradigm for treating injuries that holds that our fastest rate of healing will occur if we:
- Do not take any pain suppressive medications for an injury/painful area after the early acute phase – because these medicines mask symptoms, thus allowing us to cause further injury without realizing it; and some of them, the “NSAIDs”, also interfere with healing (NO PILLS)
- Do not engage in any activity that causes any pain in the injured/painful area – because pain is our body’s way of telling us that the activity is causing further injury (NO PAIN)
In other words (and counterintuitively) you will have NO PAIN faster if you take NO PILLS
When I discuss this with patients in my office who are injured or have arthritis, they usually state (once it is explained to them) that “no pills-no pain” is so obvious that it is amazing we treat injuries any other way. The reason we do, as explained below, is the mistaken belief that we have medications which can hasten healing (we don’t), that the medicines we take are harmless (they’re not), and that ignoring pain to an injured area is okay (it isn’t).
Why Do We Feel Pain When We Are Injured?
Pain signals us that damage or death has occurred to the cells in the affected area: for example bone and cartilage cells in a fracture or arthritis, tendon cells in a tendon rupture, or muscle cells in a torn muscle. It is also our body’s way of telling us not to use the affected area. It is remarkably specific in telling us not to perform certain activities that will aggravate the given area but letting us perform others that will not aggravate the affected area.
Our bodies are amazingly good at giving us signals as to what is okay to do with an injury and what is not. All we have to do is be good listeners as to what our bodies are telling us and not use medicines that mask those signals. Avoiding pain allows healing. Persisting in painful activities causes more damage and slows healing. What could be simpler?
The Role of Sleep
One of the most important natural factors in healing is sleep. Every day tissue damage occurs. During deep sleep the tissues are repaired. Almost everyone needs at least seven hours of sleep a night to function at their best and stay healthy, and most adults need eight. Adolescents need at least nine hours. In the 1960s the average American slept more than eight hours per night. Now, however, the average American sleeps only 6.9 hours per night. This decreased sleep worsens health in a number of ways including increased obesity and insulin resistance. However, in the current context, decreased sleep is most noteworthy for causing injuries to occur more easily and take longer to heal.
QUESTION: What “Pills” Should we avoid? (and liquids and topical creams)
ANSWER: All NSAIDs (nonsteroidal anti-inflammatory drugs) pain killers, anti-depressants, nerve medicines, and steroids – details below
NSAIDs (non-steroidal anti-inflammatory medications)
NSAIDs are a class of drugs that all function in similar ways. Biochemically, they block the synthesis of a class of chemicals called prostaglandins. NSAIDs can relieve pain, decrease inflammation, reduce fever, and act as an anticoagulant (blood thinner). The group includes the common over the counter drugs Ibuprofen (Advil and Motrin), Naproxen (Aleve), and Aspirin (Bufferin, Bayer, etc). There are also numerous prescription-only NSAIDs including Mobic (Meloxicam), Diclofenac (Voltaren), (Celecoxib) Celebrex (which is not a blood thinner), and many more.
Why Taking NSAIDs Can Be Harmful
REASON 1: NSAIDs slow healing
It is well established in scientific literature that NSAIDs slow the healing of broken bones, damaged ligament, and other tissues (1,2,3). If your body is trying to heal damage, NSAIDs can significantly impede progress and lengthen the healing time. Indeed, in my experience, discontinuing NSAIDs is usually necessary to allow healing to occur.
For example, the following is a transcript of a video on our website of a patient of mine who had been in severe pain, who I had asked to stop taking her prescription NSAID pills before performing a PRP injection.
“It was unbelievable. I didn’t want to stop because I had been living on these pills for months and months. I stopped and within three days I started to feel better. The swelling in my knee also started to go down, and I was totally surprised. Now it’s a month later and I have no pain at all.”
REASON 2: NSAIDs block pain, thus masking symptoms
When you take an NSAID, you feel better because the drug blocks the feelings of pain that your body is producing. However, NSAIDs do not help the problem resolve; they only keep you from feeling pain from it for a while. Pain is your body’s way of telling you that something is wrong and damage is being done to some part of your body. When you don’t feel the pain because of a drug, you may use the injured area more and actually hurt it more severely because you are not feeling the pain. When the medication wears off, the problem and the pain may be worse than before. Or, if you keep taking the pain pills, eventually the pain will become so severe that you will feel it even while you are still taking the drug. If you decrease painful activities promptly, most musculoskeletal problems will resolve and the damage will reverse. If you wait until the pain (and therefore, the damage) is much worse, it may be much more difficult to eliminate the pain. For example, a patient with a partially torn rotator cuff in the shoulder can usually heal if they rest their shoulder. However, taking pain medications or getting cortisone shots will diminish their pain and allow greater use of the arm. This results in an increased chance they will tear the tendon completely and require surgery – which could potentially have been avoided.
REASON 3: NSAIDs can cause ulcers and gastrointestinal bleeding that can be fatal; as well as kidney, liver, and heart problems
NSAIDs can cause stomach and intestinal ulcers. Therefore, at the first sign of stomach upset, they should be discontinued. Continued use can lead to severe and sometimes fatal GI bleeding. In fact, it was estimated in a New England Journal of Medicine article that 16,500 deaths occur in the U.S. every year from NSAID use (4), primarily from GI bleeding. Kidney, especially, and also liver failure occur with some regularity, and newer data also shows an increased incidence of heart problems (5). They can additionally be a trigger for asthma attacks.
Other Pain Killers (Analgesics)
The following are the main pain killers in common use besides NSAIDs. Unlike NSAIDs, they do not directly interfere with healing, nor do they have serious ulcerogenic and GI bleeding side effects. However, they all still can interfere with healing by masking pain and, thus, allowing you to continue to hurt yourself without knowing it.
Acetaminophen is not an NSAID. Used in moderation, it is a safe drug, but in high doses it can cause liver damage. If an over-the-counter pain killer must be taken, it is usually a better choice than an NSAID. High doses of Acetaminophen leading to toxicity is the second leading cause of liver damage in the United States after alcohol use.
Tramadol is a mild narcotic prescription pain reliever. It is a relatively safe drug often combined with acetaminophen. It can cause drowsiness and constipation, especially in older people.
All narcotics are prescription drugs. Commonly prescribed narcotics for musculoskeletal problems include hydrocodone (Vicodin), oxycodone (Percocet), and codeine (Tylenol 3). The most common side effects of narcotics are constipation, altered mental state, and respiratory suppression which can be fatal; and they are highly addictive.
- Pills – Prednisone and Medrol Dosepaks are the common oral forms of corticosteroids, commonly called “cortisone.” They impair healing, promote osteoporosis, infections and truncal obesity, aggravate diabetes, and can cause terrible side effects such as avascular necrosis of the hip. They should not routinely be used for moderate musculoskeletal injury.
- Injections – They may reduce pain but repeated injections accelerate tissue destruction and can cause infections, which can be life threatening. When injected into tendons, they predispose the tendon to rupture. They can also cause an unsightly puckering from “fat atrophy." By masking pain, they can also contribute to increased tissue damage.
Cymbalta, Elavil, Lexapro, Paxil, and Prozac are examples of anti-depressants which are sometimes used for pain, usually chronic pain. This is often called “fibromyalgia” when multiple joints are affected. In fact, these medicines are highly addictive, produce unwanted cognitive effects, and are subject to an FDA warning that, in patients under 25 years of age, can increase suicidal ideation. They also do nothing to treat the underlying problem and can encourage providers to abandon the search for real underlying causes by giving a false sense that something useful is being done for the patient. It is always easier to prescribe a pill for a symptom than to find and treat the problem that underlies the symptom. In my opinion, they should never be used for musculoskeletal problems.
There are two commonly used and related drugs in this class: Gabapentin (Neurontin) and Pregabalin (Lyrica). If there is a bonafide diagnosed nerve injury, these drugs can be useful. However, they are often prescribed for vague nerve-like symptoms and because they also have a weak pain-killing effect. However, they can cause drowsiness and a clouded mental state, especially in older people.
Sports and other Creams, Pain Patches & Braces
- Sports creams are “liniments” that work by causing a mild chemical burn of the skin. This does nothing to treat the underlying problem but merely “distracts” the pain fibers of the nervous system from sensing the pain due to tissue damage.
- Voltaren (Diclofenac) Cream is a topically applied NSAID, but it is absorbed into the blood and can cause the same serious side effects, healing- inhibition, and symptom-masking as when taken orally; they should be avoided.
- Pain patches work by supplying a local anesthetic to the local area. Again, they do not help healing in any way.
- Braces/wraps (for the knee, elbow or elsewhere) apply local pressure to the painful area. They also do not help healing in any way. They do not “support” the affected part in a way that improves healing. They do diminish the feeling of pain by flooding the nervous system with signals and, thereby, also encourage increased use of the affected part and increased damage.
What all of these methods – sports creams, pain patches, and braces – have in common is that they do not help the injury heal, but do mask pain symptoms and, thus, encourage damaging overuse. This is the same thing that happens with pain pills. People may well heal in spite of these pain killers, but they will not heal faster. And often they will heal more slowly, sometimes needing more extreme treatment, such as surgery, that could have been avoided had they simply let the body heal itself without interfering with the healing process.
Ice and Cold Therapy
It may surprise you to know that there is no evidence that cooling an injured part helps it heal. Cold has two effects. First, it can decrease blood flow to an area and decrease swelling. But our bodies specifically increase blood flow to an area to bring nutrients and growth factors there to help healing. There is no evidence that it is useful to diminish this natural response to injury. If there is massive swelling, then elevating the affected part is most effective and ice may be useful. It is generally imprudent to initiate a treatment that counters part of our natural healing response – the swelling that brings nutrients to the injured area – without a good reason to do so.
The second effect of ice is as a pain reliever. If pain is severe, then cold is generally a better and safer alternative to medications that can have side effects. Just make sure that ice in not applied directly to the skin, which can result in an ice “burn.”
Is Immobilization Beneficial if there are no broken bones?
Usually not – with some exceptions. Immobilization has also been shown to produce weaker ligament healing. It turns out that a certain amount of – painless – motion is helpful to allow maximum healing.
Immobilization is useful for certain problems such as a true knee dislocation or patellar dislocation, and for fractured bones. Your Orthopedic Surgeon will tell you on a case-by-case basis.
How About Night Pain: If Sleep is Useful, Shouldn’t Patients Take Pain Pills at Night to Facilitate Sleep?
Traditional sleeping pills induce abnormal sleep as measured by EEG activity. Night pain is almost always caused by excessive painful activity during the day. We feel pain more at night because our nervous system has less other sensory input to distract us from our pain. However, it is easy to fall into a vicious cycle of excessive activity during the day, causing pain at night which is then masked with a pain pill and a sleeping pill, allowing you to continue the excessive – and destructive – activity during the next day. Not taking a pain or sleeping pill forces you to take it easy on yourself, resulting in the elimination or at least diminution of the night pain. The night pain is your body’s way of telling you to take it easy during the day. If you do, you will feel better; you will sleep better naturally, and you will heal more quickly because you are not continually aggravating the injured area.
Why are these Non-Helpful Treatments So Popular?
The reason that all these methods are popular is because people, understandably, want to avoid pain and get back to doing everything they were before the injury as quickly as possible. Also, clever marketing has left consumers with the impression that these medications and other treatments can help them heal faster. The ads don’t come out and say this directly. They can’t because it is simply not true and this is well established in the scientific literature. But, the impression of hastened healing is cleverly implied. NSAID ads say they decrease “inflammation” without pointing out that the inflammatory cascade, which NSAIDs partially block, is necessary for healing. Interfering with this wondrous biological process interferes with healing. The inflammation isn’t the problem; the injury that causes the inflammation is. Inflammation in the setting of injury (as opposed to an autoimmune disease such as rheumatoid arthritis for example where the inflammation is the problem) is part of the solution to the problem of the injury and should not be interfered with, except in certain circumstances.
In my experience, most patients do not like taking pills or using other treatments that are only pain killers. The appeal of these treatments is that patients believe they speed up healing. Once I tell my patients that faster healing does not occur, they usually want to stop taking the medication or treatment, particularly when they understand that they can have dangerous side effects as well.
What to Use Instead of NSAIDs or Other Pain Medication
Crutches or a Walker
If the problem is below your waist (knee, ankle, etc.) and you have pain with walking, then using crutches or a walker (a cane is not helpful) with partial weight bearing is absolutely essential to lessen your body weight on the joint and give it an opportunity to heal. You should walk with a normal gait but take enough weight off by using your arms to eliminate pain. It can be helpful for back pain as well.
If the problem is in your arms, simply avoid any activity that causes pain. For the shoulder, keeping your elbow near your side is very helpful. For the elbow, wrist, and hand, simply avoid painful activities and rely on the other hand. Every musculoskeletal injury can be helped in this way. The trick is finding ways to put the injured body part at rest while keeping your whole body functioning.
How about Physical Therapy?
Physical therapy can be helpful, but can also be harmful and should not be painful. The one exception is when therapy to stretch a contracted joint is necessary. This may be painful, but is nonetheless beneficial and necessary in some cases. However, pain from strengthening or other physical therapy treatments should not occur. If it does, it is a signal that, although you are strengthening muscles, you are also causing damage. Strengthening in and of itself does nothing to help an injured joint heal.
While gentle passive stretching to restore normal joint motion and normal gait is useful, aggressive stretching can cause increased tissue trauma and aggravate the problem, and should not be performed. Stretching of a damaged tendon can increase tendon damage.
The same idea holds true for “deep tissue massage:” kneading or probing injured tissue, despite pain, is simply causing further injury. The often cited rationales that such treatments increase circulation or remove scar tissue have no basis in scientific fact.
Over-the-counter nutritional supplements may be helpful. These are not pain pills, do not alter your mental state, and are very safe when appropriately used. I have extensively studied the scientific literature to understand which ones have shown clinical efficacy in humans (as opposed to laboratory animals) in controlled studies, and in what doses; and this information is available on our website. However, for purposes of this article, I would mention that glucosamine and chondroitin, curcumin (from turmeric), 5-lipoxin (from boswellia), Avosoy (avocado-soy unsaponifiables), UC-2 (undenatured type two collagen), Hyaluronic Acid, Uncaria Tomentosa (Cat’s Claw), Ginger Root, Commiphora (from Myrrh), and MSM (methylsulfonylmethane) are the primary supplements that have shown scientifically validated efficacy. They are, however, often sold in inadequate doses in proprietary mixtures and often do not contain what they say on the labels. They are also unregulated, so it is important to find tested (usually GMP certified) manufacturers to avoid contaminants and impurities.
We maintain a website of GMP certified tested supplements in the proper doses as shown in the scientific literature. You may visit our website for more information on nutritional supplements or contact us for more information.
Can the New PRP (Platelet Rich Plasma) and Stem Cell Treatments Derived From Your Own Body Help Healing
Yes. As discussed above, there is no pharmaceutical drug yet discovered that hastens healing. However, your own growth factors - which are concentrated and injected as PRP or Stem Cell Treatment after a simple blood draw, bone marrow aspiration, or fat lipoaspiration - are a recent, exciting, and safe medical breakthrough and are the first treatments discovered that actually can help you heal faster and better. However, these treatments should only be used if your body has failed to heal on its own. You should also be wary of such treatments derived from the tissue of other people for reasons of both safety and efficacy.
No one knows your body better than you. If you listen to what it tells you, you can respond in ways that help instead of hurt. As mentioned above, our bodies have a fantastic natural healing mechanism to heal our injuries. When you reduce, modify, or eliminate activities that cause pain, you give these mechanisms a chance to work. This is absolutely your best opportunity to heal. Pushing through pain or taking potentially toxic and non-helpful medications will only get in the way of your body’s natural healing powers.
And beware of false claims of accelerated healing promulgated through misleading or simply false advertising. Learn to be a skilled interpreter of what your body is telling you; be aware that pain is a necessary, useful signal to be heeded, not muffled and masked. If you avoid pills and avoid activities that cause pain (“no pills, no pain”) you will optimize healing. You will also save time and money.
If you have a question for Dr. Prodromos, leave it in the comments below.
See These Published Papers for Additional Information
- Indomethacin and celecoxib impair rotator cuff tendon-to-bone healing. Am J Sports Med. Cohen, et al. 2006.
- Healing of experimental muscle strains and the effects of nonsteroidal antiinflammatory medication. Am J Sports Med. Almekinders & Gilbert. 1986.
- The Effect of Ketorolac on Anteroposterior Knee Laxity After Anterior Cruciate Ligament Reconstruction. Orthopedics. Mehta, et al, 2008.
- Gastrointestinal Toxicity of Nonsteroidal Antiinflammatory Drugs. New England Journal of Medicine, Wolfe, et al. 1999
- Cardiovascular Risk of Nonsteroidal Anti-Inflammatory Drugs: An Under-Recognized Public Health Issue. Varga Z1, Sabzwari SRA1, Vargova V2., Cureus.2017 Apr 8;9(4):e1144. doi: 10.7759/cureus.1144.