First, do no harm

The Latin phrase, “primum non nocere,” loosely translated as, “first, do no harm,” was introduced into modern health care by Worthington Hooker in his 1847 book, Physician and Patient.

The Latin phrase, “primum non nocere,” loosely translated as, “first, do no harm,” was introduced into modern health care by Worthington Hooker in his 1847 book, Physician and Patient. While chiropractors do not commonly treat high-risk conditions and the methods we employ are far safer than many medical interventions, we still have a responsibility to “do no harm.”

This may mean intervening when care being provided by others is not in line with current research. For example, patients may report that a doctor has advised heat and bed rest for an acute low back injury. Prescribing and monitoring medications is not part of chiropractic practice, but we’ve all had patients who are taking potentially harmful prescribed medications.

I recently interviewed a new patient who presented with a chronic shoulder issue. When asked about his current medications, he reported long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) had “ruined” his stomach. I suspect had he been properly monitored, the outcome would have been different.

The risks of NSAIDs are well known. In a recent online article for Spine-Health, Dr. Peter Ullrich Jr. reported on the potential risks for NSAIDs. He stated: “Most types of NSAIDs have a variety of potential risks and complications associated with them. While most side effects are rare, some can be serious and even potentially fatal, so it is important for patients to remain aware of them and under supervision by a health professional.”

A review undertaken by the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group concluded: “There is overwhelming evidence linking these agents to a variety of gastrointestinal toxicities.”

Surprisingly, these drugs are not considered dangerous by many patients. This may be due to their easy availability. While ibuprofen 600 mg is available by prescription only, you can buy a 400 mg dose at any drugstore. Aleve, which contains 22 mg of Naproxen, became available as an over-the-counter medication in most provinces in Canada in 2009. The good news is that many patients are becoming aware of the risks and are seeking other ways to deal with pain and inflammation.

This is where chiropractors can be of help.

Topical analgesics may contain varying concentrations of menthol, capsaicin, methyl salicylate or trolamine salicylate. With more research, the specific mechanism of action and value of each is becoming clearer.

Substance P has been implicated in the pathogenesis of inflammation and pain in arthritis. A 1991 study published in Clinical Therapeutics examined 70 patients with osteoarthritis and 31 with rheumatoid arthritis. This study found that 80 per cent of the patients treated with topical capsaicin experienced a reduction in pain after two weeks and concluded that capsaicin cream is a safe and effective treatment for arthritis. A study published in Molecular Pharmaceutics supported the therapeutic potential for methyl salicylate in treating inflammatory diseases. Due to its counterirritant properties, menthol stimulates the type 2 C fibres, triggering the release of Substance P. Once this substance is depleted, the pain signals are temporarily blocked.

In contrast to the safety of topical analgesics, NSAIDs pose a significant risk of kidney and gastric damage. The Cochrane Back Group published a review in 2010, which found statistically significant effects in favour of NSAIDs compared to placebos, but at the risk of significant side effects. This is where we can fulfil our “do no harm” role.

NSAIDs may be a good choice under certain conditions, but overuse is often a problem, particularly when your patients are self-medicating with OTC Naproxen or ibuprofen. Recommending a topical analgesic can reduce these risks and can be more effective in controlling pain and inflammation. However, be aware that some readily available topical applications do contain NSAIDs, such as Diclofenac. Using this as a topical agent may reduce inflammation and relieve pain, but it comes with the same cautions and warnings as oral Diclofenac.

The website of a commonly used topical brand advises that NSAID medicines may increase the chance of a heart attack or stroke and can cause ulcers and bleeding in the stomach and intestines at any time during treatment. Fortunately, there are many other highly effective products now available, which do not contain NSAIDs. Selecting the appropriate active ingredient still does take a bit of homework.

As a guide, for acute injuries to muscle and joints, we commonly recommend the RICE protocol (rest, ice, compression, elevation). For these situations, a product containing menthol would be helpful. The chronic inflammation and pain associated with degenerative arthritis responds well to warming agents such as capsaicin, trolomine or methyl salicylate. Tightness in the neck and upper back is best relieved by a combination of warming and cooling agents, such as menthol and methyl salicylate.

The wide variety of applications makes it easy to recommend the product that would be most beneficial to your patient. Topical analgesics are widely available as patches, creams, gels or sprays in odour-free or regular formulations. Steering your patients toward the appropriate topical analgesic can enhance the results of your treatment, reduce their levels of pain and increase their levels of performance.

By reducing their risk for gastric, kidney and other complications, you are ensuring that no harm is done. By adding this advice to your treatment program, you are enhancing the value of the services you provide to your patients.

Dr. David Leprich is clinic director at Welland Avenue Chiropractic And Massage Therapy, which he established in 1977. He is a past president of the Canadian Chiropractic Association, a current board member of the Canadian Chiropractic Research Foundation and Theatre Chiropractor to the Shaw Festival Theatre in Niagara-on-the-Lake. Dr. Leprich can be reached at davidleprich@bellnet.ca.