Daniel S. Bennett, MD, DABPM is an interventional spine/pain medicine physician from Denver, Colorado. He is the Founder and immediate past-Chairman of the Board of Directors of The National Pain Foundation. He is also an Associate Clinical Professor of Anesthesiology and Pain Medicine at University of Colorado Health Sciences Center and lectures nationally and internationally on pain medicine. SpineUniverse talked to Dr. Bennett about the management of chronic pain, particularly in light of recent controversies of many prescription pain medications.

SpU: Dr. Bennett, many patients who were previously prescribed VIOXX® to treat chronic pain from conditions such as spinal osteoarthritis are now searching for other avenues of pain relief. What other types of prescription medications are available to relieve chronic pain of this type?

Dr. Bennett: In addition to NSAIDs (non-steroidal anti-inflammatory drugs), of which VIOXX® is a member, there are other drugs of the opioid (or narcotic) class. These agents vary in their potency, from weak (tramadol) to moderately potent (hydrocodone) to potent (morphine or fentanyl). While these medications are not for everyone, they can help increase mobility and function, which can improve the quality of a patient's life. This, by the way, is the foremost indicator for success of any treatment whether it is medication, surgical, or other. The opioid medications have no known direct damaging effects to the organs, unlike the non-steroidal anti-inflammatory drugs, which have been associated with gastrointestinal and liver problems in some patients.

SpU: There are many over-the-counter (OTC) medications that patients can purchase. Are these as effective as a prescriptive drug to reduce pain? Are there certain 'types' that are more effective in relieving pain?

Dr. Bennett: There are many OTC medications available to reduce pain inclduing aspirin, ibuprofen and acetaminophen. Aspirin and ibuprofen are included in the class of non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen is a non-steroidal analgesic with fever-reducing properties (but no anti-inflammatory effects), newly classified as a COX-3.

The OTC variants of these drugs are the same as the prescription versions, only the amount of the drug is less. This can be seen in the number of milligrams (mg) in each tablet or pill. They are just as effective as the prescription grade medications of the same name. However, these medications are only of one particular class (i.e. non-steroidal anti-inflammatories); if you do not respond to a NSAID (or cannot take a NSAID), you may need a different medication.

As a general rule, you should not use any NSAID for greater than three weeks unless your physician says it's ok to do so. Keep the following maximum daily doses in mind:

• Ibuprofen: do not exceed 1200 mg in 24 hours
• Acetomenophen: do not exceed 2000 mg in 24 hours

It is important to remember that dosage depends upon the health of your liver and kidneys. The above numbers are only guidelines. ALWAYS consult with your physician regarding how much of a medication you should take.

SpU: Is it safe for patients to take an OTC medication along with their prescribed pain medication?

Dr. Bennett: You should never take OTC medications and prescription medications without consulting your physician (this includes herbal and homeopathic remedies!)