Pain medication risks and the alternatives

Paul Reller, L.Ac.

In the last decade we have seen nonsteroidal antiinflammatory medications taken off the market (re: the Vioxx scandal), enormous fines for off-label drug promotions of Cox-2 inhibitors, black box warnings of risks for NSAIDS, the creation of legislation to curb chronic overuse of narcotic pain medication due to a large number of overdose deaths and injury in common medical use (over 14,800 overdose deaths in 2008 from opiod pain relievers alone), and now sharp restrictions by the U.S. FDA of common pain medication use due to the large number of deaths and injury attributed to acetaminophen (paracetamol) poisoning, mostly from chronic use of narcotic pain relievers and high dosage over-the-counter drugs. In addition, the alarm bells have gone off concerning the high incidence of harm from concurrent use of ibuprofen with acetaminophen, although dealing with this common problem is difficult. We are still trying to formulate successful guidelines to prevent the large number of deaths and injury from overuse of aspirin and other NSAIDS concerning gastric ulcers and gastrointestinal bleeding. In addition, prescription pain medications now comprise the largest category of drug abuse in the U.S., much of which comes from teenage use of parent's pain relieving narcotic medication, and the illicit diverting of pharmaceuticals to the street market, via burglaries, prescription forgeries, employee theft, and “doctor shopping”, as well as illegitimate prescribing, and diverting of pharmaceutical “samples” by drug representatives. Added to these types of harm is the increased risk of birth defects noted in patients that were taking narcotic pain medication preceding pregnancy and during the first trimester (see the link to the study summary below). Patients and doctors are now looking more seriously at an alternative to the enormous reliance on pain relieving medication, and Complementary and Integrative Medicine is supplying healthy and safe alternatives to controlling pain with drugs, including acupuncture, physiotherapies, herbal and nutrient medicine, and patient instruction in therapeutic activities.

While treatment of pain in Complementary Medicine may not be as easy as taking a pill, the effects may be much more beneficial in the long term. TCM, or the medical specialty of Traditional Chinese Medicine, commonly just referred to as ‘acupuncture’, provides patients with a comprehensive possibility of treatments to not only relieve pain, but to correct the underlying causes of the pain, and promote better tissue healing. The TCM specialty also offers the potential of real neurological modulation of pain hypersensitivity and syndromes of neuroimmuno-psychopathologies, such as fibromyalgia, as well as correction of underlying neurohormonal problems that inhibit proper tissue maintenance and repair. Studies in recent years show that patients utilizing a multidisciplinary treatment approach, instead of opioid pain medication, had a chance of recovery from a chronic pain syndrome almost 4 times as high, with a significantly greater health-related quality of life.

TCM physicians may utilize acupuncture stimulation, electrical stimulation, diathermy, herbal and nutrient medicine, mind-body medicine with cognitive and behavioral modification, and even direct soft tissue physiotherapies, called Tui na in China, which encompasses myofascial release, neuromuscular reeducation, and a variety of techniques of tissue mobilization. Even newly researched techniques such as low intensity laser therapy are included in the scope of practice of the License of Acupuncture. Acupuncture, in recent years, has been heavily researched to discover how it relieves pain. Despite the problems of gauging the effects of acupuncture on humans with a randomized comparison to placebo (obviously there is no such thing as a true sham placebo when actually sticking a person with a needle and manipulating it effectively), almost all human clinical trials of acupuncture for the relief of pain show significant pain-relieving effects. Since the “placebo effect” is part of the real effect in acupuncture, stimulating the mind-body mechanisms to change pain perception, the question of whether acupuncture only works via this “placebo effect” has been much publicized. Research in recent years has proven that there are beneficial types of “placebo effect” that result in measurable improvement, and TCM has adopted this mind-body effect for centuries, although most of the effects in TCM practice are direct and practical, not the result of a placebo. We have known that levels of circulating endorphins and dynorphins, which are opioid neurotransmitters that our bodies use to moderate pain signals, significantly rise with acupuncture stimulation, and that a course of repeated acupuncture stimulates a long lasting rise in these chemical mediators. The mechanisms of pain relief, and the objective scientific elucidation of this “placebo effect”, though, have been more thoroughly revealed in the last decade with sound research at the most prestigious universities in the United States, perhaps due to the amount of skepticism shown in standard medicine. There is no single way that TCM relieves pain, but rather many ways.

In 2009, researchers at the University of Michigan Chronic Pain and Fatique Research Center used three forms of brain imaging to assess the objective effects of acupuncture stimulation on the areas of the brain that perceive and modulate the pain signals, especially in chronic pain, which is often heavily subjective and tied to memory and emotion. This study, published in the medical journal Journal of NeuroImage in September of 2009, found that simple acupuncture needle stimulation alone increased the binding ability of mu-opioid receptors (MOR) in regions of the brain that process and dampen pain signals - specifically the cingulate, insula, caudate, thalamus and amygdala (see the article entitled Brain Health and Function on this website to learn more). “The increased binding availability of these receptors was associated with reductions in pain”, stated the head researcher, Dr. Richard E Harris, Ph.D., an assistant professor of anethesiology at the University of Michigan School of Medicine. The human study participants in this initial clinical trial were diagnosed with fibromyalgia. The researchers stated that the implications were that acupuncture needle stimulation alone may not only relieve chronic pain, but also increase the effects of narcotic pain relievers, thus reducing the dosage needs. When combining this needle stimulation with the other TCM modalities, especially the direct soft tissue physiotherapies to correct the causative problems, and the use of herbal and nutrient medicines and mind-body medicine to improve physiological function, decrease inflammatory dysfunction, balance the neurohormonal responses, and effect other circulatory and tissue healing effects, Complementary Medicine shows that this holistic approach is not only scientifically sound, but should be the preferred alternative to chronic use of pain medication for any patient that is actually looking to get well and not just ‘manage’ their pain.

The medical practice that we call acupuncture involves much more than just the needle stimulation, though. Direct soft tissue therapies, along with herbal and nutrient medicines, help to heal the injured and degenerated tissues that are the cause of most pain. To actually treat this underlying cause is the most practical way of getting rid of the pain permanently. Merely medicating only perpetuates the pain syndrome, and the alarming rise in the number of deaths and adverse health effects attributed to pain medications should be a wake-up call to both physicians and patients. In 2011, the U.S. Centers for Disease Control and Prevention (CDS) released a report that found more than a tripling of the number of yearly deaths attributed to narcotic pain reliever use over a ten year period. These prescribed pain medications led to the death of more than 15,000 patients in 2008 in the United States, a steady rise from 4000 overdose deaths in 1999. The CDC report shows that nearly 5 percent of Americans say that they have abused narcotic pain medications in the past year, and so many narcotic pain prescriptions are now written that the total would give every American a one month supply, says Dr. Thomas Frieden, director of the CDC in Atlanta, which issued this report. Talk about drug pushers. Dr. Frieden describes this as an epidemic, and told an Associated Press reporter that, in his opinion, doctors should limit prescriptions, giving only enough for acute pain episodes, and look for alternative treatments. The time has come for medical doctors to utilize more conservative therapies to correct the problem of pain, and the skilled Licensed Acupuncturist, along with Chiropractors, Physical Therapists, and Osteopathic doctors can provide this conservative care. The patient population as well as the general public, and public health authorities, need to demand a change. When totalling the number of deaths attributed to the various types of pain medication, narcotic, non-steroidal anti-inflammatories (NSAIDS), acetaminophen, and steroidal medications, the yearly number of unnecessary deaths is now astounding.

The Centers for Disease Control and Prevention (CDC) released a statement in January of 2012 that stated that in every year since 2003, more Americans have died from prescription painkiller overdose than from heroin and cocaine combined (the numbers in fact eclipse the actual heroin and cocaine overdose deaths). Overdoses are now the most prevalent cause of accidental death, mostly from prescription painkillers, surpassing deaths from motor vehicle accidents. The “war on drugs” appears to have shifted the profits to the pharmaceutical industry, and the results have been devastating in the United States. The cause of death often involves the effects from concurrently prescribed drugs as well, especially the combination of pain medications with drugs that treat anxiety and depression. The combination of these drugs with alcohol or other recreational drug use also increases the risks of accidental overdose and death, as well as liver, endocrine and neurological damage. Still, there is very little effort on the part of standard medicine to shift away from prescription painkillers, and utilize healthy, safe and effective treatments in Complementary Medicine. Programs such as the 2009 prescription drug monitoring system, set up by Governor Jerry Brown, are not even utilized. The New York Times reported that in the San Francisco Bay Area, only 86 of 30,000 doctors and pharmacists have signed up to use the system in 2011. This online system could quickly identify prescription drug abusers and “doctor shoppers”. Prescription painkillers are the most abused serious drugs among youth in the United States, and many teenagers buy these pills from such alleged patients. By 2012, budget cuts resulting from the Great Recession have all but eliminated these programs of pain medication abuse in many states. Most of these abused opioid pain medications have a high dosage of acetaminophen as well, creating a risk of liver damage or dysfunction, especially when the buffering is broken down and the drugs are snorted or injected.

In 2011, the U.S. FDA announced that sharp restrictions of acetaminophen content in some of the most popularly prescribed pain medications would have to occur over the next 3 years, or these drugs would be taken off the market. The FDA will also require more explicit label warnings on these prescription medications concerning the risk of acetaminophen overdose and liver damage. Drugs combining opioids and acetaminophen are prescribed more than 200 million times per year, and use of high dosage acetaminophen has become commonplace in drug prescription as more effective simple narcotic medications have been heavily restricted and discouraged.

The Public Citizen's Health Research Group, with Dr. Sidney Wolfe, director, and Dr. Peter Lurie, deputy director, have been at the forefront of a 30 year campaign to address the unspoken and unpublicized dangers of damage from overuse of the most common pain relieving drug, acetaminophen. In 1977, the FDA (Food and Drug Administration) Advisory Review Panel recommended that strong warnings be placed on all acetaminophen-containing medications: “Do not exceed recommended dosage because severe liver damage may occur” and “Do not exceed recommended dosage or take for more than 10 days, because severe liver damage may occur.” By 1999, the failure to enforce even these FDA warnings of liver damage resulted in the National Hospital Discharge Survey finding that over 26,000 hospitalizations per year related to acetaminophen overdose were recorded. This was despite a reluctance to record acetaminophen poisoning by the standard medical industry. The National Hospital Ambulatory Care Survey reported nearly 57,000 emergency room visits per year related to acetaminophen injury, and the American Association of Poison Control Centers recorded 108,000 calls to Poison Control Centers in 1999 regarding acetaminophen poisoning, and 141 deaths. A review of death certificate data resulted in an estimation of 458 deaths per year related to acetaminophen use or misuse, and the reluctance to record and report indicates that this figure is probably very underestimated. These recorded figures had doubled since 1995, were widely considered underreported and underrecorded, and were expected to increase yearly unless more intense regulation and warnings were enforced.

In 2011, a study published in the British Journal of Clinical Pharmacology concluded that many of the overdose deaths caused by acetaminophen, found both in common pain relievers and combined with synthetic narcotics in prescribed pain medications, were caused by “staggered overdoses”, with patients exceeding safe dosages over a period of time. These overdoses, resulting in various health problems ranging from liver damage to death, are difficult to diagnose, as the level of acetaminophen in the blood circulation is too low to trigger an overdose warning. With a succession of overdoses, gradual liver damage may occur, and in these cases, addition of alcohol increases the chance of serious liver damage or death. The addition of alcohol also makes the objective assessment still more difficult. The result, according to experts, is a severe underreporting of injury and deaths caused by acetaminophen overdose.

The overuse of acetaminophen seems to be a response to even greater harm from the other common pain medications. In 1998, The American Journal of Medicine, in the July, 1998 issue, stated: “Conservative calculations estimate that approximately 107,000 patients are hospitalized annually for non-steroidal anti-inflammatory drug (NSAID)-related gastrointestinal (GI) complications and that at least 16,500 NSAID-related deaths occur each year among arthritis patients alone. The figures of all NSAID users would be overwhelming, yet the scope of this problem is generally under-appreciated.” In 1999, the prestigious New England Journal of Medicine reported that the figure of deaths attributed to NSAID use in rheumatoid and osteoarthritis patients alone was considerably greater than the number of deaths attributed to AIDS, multiple myeloma or cervical cancers, asthma, or Hodgkin's disease. It was estimated that if NSAID deaths from GI bleeding were tabulated separately in national reports that it would constitute the 15th most common cause of death in the United States. By 2009, experts agreed that the number of deaths and adverse events attributed to NSAIDS each year in the United States has at least remained unchanged over the last ten years. The FDA suggests that up to 20,000 deaths per year could be attributed to NSAID use and GI bleed. Obviously the increase in the acetaminophen alternative did not have the desired effect.

This cavalier attitude toward pain medication prescription and usage has evolved because of the reluctance to prescribe actual physiotherapies that both relieve pain and promote clearing of unhealthy tissue and regrowth of healthy tissue with injury and chronic pain syndromes. The reasons for the development of this attitude in medicine are multifactorial. Medical doctors were led to believe that physicians and therapists that performed these various physiotherapies, such as Licensed Acupuncturists, Chiropractors, Osteopaths, and Physical Therapists, presented a significant economic competition to their profession. Insurance companies discouraged the authorization of these physiotherapies to cure and relieve pain, presenting further disincentive to medical referral and prescription. The end result was not an economic savings for the public, as the alternatives to these physiotherapies, drug dependence and surgery, as well as disability and missed work, added up to an enormous cost, both in the price of insurance policies, and to the tax burden and cost to business in the United States. In addition, the underlying causes of slow healing and chronic pain, which may relate to a variety of health problems, were not being addressed. A holistic approach is often needed to actually address these underlying causes. Circulatory problems related to Metabolic Syndrome and poor tissue repair and maintenance related to hormonal imbalances are just two common examples related to chronic pain. Myofascial pain syndrome is perhaps the most important of these underlying causes, and is rarely addressed with any therapy today. Increased use of Complementary Medicine and the properly trained and knowledgeable Licensed Acupuncturist will dramatically decrease drug dependence and the problems associated with excessive use of pain medication.

The total number of people in the United States that have died due to NSAID use is estimated to be over 300,000, which is greater than the combined American deaths from World War I, the Revolutionary War, the War of 1812, the Spanish-American War, the Korean War, the Vietnam War, and the Persian Gulf war combined. With estimates of 20,000 deaths per year by the FDA, this indicates that a great number of patients are injured to a lesser degree as well from non-steroidal anti-inflammatory pain medications, usually from chronic use.

Not only NSAIDS and acetaminophen are causing an alarming number of deaths, injuries and ill health, but narcotic pain medications are eliciting a growing alarm each year. In 2010, pharmacies received and dispensed the equivalent of 69 tons of of pure oxycodone (Oxycontine, Percodan and Percocet), and 42 tons of pure hydrocodone (Vicodin, Norco and Lortab), enough to give 40 5mg Percocets and 24 5mg Vicodins to every person in the United States. This does not include the illicit traffic in these pharmaceutical drugs, creating an enormous amount of narcotics provided by the pharmaceutical industry to the population. A growing number of these prescriptions are provided online with little oversight, with pharmacies freely dispensing prescriptions procured by individuals who have not even met the prescribing medical doctor. Most of these narcotic pain medications, both prescribed, or procured on the street, contain acetaminophen. The number of NSAIDS, COX2 inhibitors and doses of acetaminophen alone, eclipse this number of narcotics, creating a pain medication use that is astronomical. The need to promote other medical protocols to relieve pain is a question of national emergency, yet standard medicine is still not properly promoting pain relief from increased use of such proven methods as acupuncture, traditional physiotherapies, herbal and nutrient medicines, and patient instruction in traditional self-administered protocols of pain relief and rehabilitation. In fact, the fervent zeal to restrict these proven therapies, even in the realm of Workers' Compensation law and occupational medicine, despite strong endorsement from the World Health Organization, the National Institutes of Health, and the California Industrial Medical Council, has been incredible. Failure of the federal and state governments to mandate insurance and governmental benefits for professional Complementary Medicine from Licensed Acupuncturists has resulted in an enormous underutilization of a safe and low-cost treatment proven to be effective in both pain relief and cure of most causes of chronic pain. Since there is no real alternative to these harmful and dangerous pain relieving medications in standard medicine, the failure to integrate and promote Traditional Chinese Medicine into the pain treatment protocol is now beyond controversial. This is a health care crisis. Continuing to give the impression to the public that these common pain relieving medications, both prescription and nonprescription, are harmless, is shameful. Use of pain relieving medication is, of course, essential in modern medicine, but only in safe dosage, and only in short courses of therapy. Promotion of chronic use of these drugs is unacceptable when safe alternatives exist with sound proof of medical efficacy. The public needs to become aware and speak up, for its seems that this crisis will never be addressed until there is public outrage and demand.

In 2012, the public is still told that acupuncture, herbal medicine, and physiotherapies of Traditional Chinese Medicine are still not utilized due to a lack of belief in their efficacy. This is no longer true. Scientific study now provides ample proof of efficacy. These safe and effective therapies are underutilized due to lack of access and payment. Our government has not passed laws recognizing the public right to these effective therapies, had not passed legal recognition of the profession of acupuncture and Traditional Chinese Medicine, and has not recognized these therapies in the Medicare system. There has been no mandate passed to insure the freedom of choice of patients covered under health care plans, both public and private. There is little inclusion in medical guidelines, and still an economic mandate on the part of insurance companies to restrict payment for these effective therapies. There is no question of the merits, and less and less question of the economic advantages to these low cost and effective therapies. In the realm of pain relief and treatment of musculoskeletal injury and painful disease, there is no longer a question of merit and efficacy. There is an obvious need to incorporate these therapies, as this article points out. Knowledge of the risks involved in chronic use of pharmaceutical pain medication is the first step in understanding the need for increased utilization of TCM.

Understanding of the safe and unsafe levels of acetaminophen (paracetamol)

Today, almost all narcotic pain medications contain more, or an equal amount of, acetaminophen than the FDA Advisory Panel found to be a safe maximum in 1997, and the number of over-the-counter pain relievers in drugstores with at least 325 milligrams of acetaminophen has increased greatly. The public is not aware of what they are taking, or the risks and unseen damage. The array of brand names with high dosage acetaminophen, and combinations of other drugs with acetaminophen is now incredible, and many patients suffering from chronic pain take more than one medication with acetaminophen included in the drug, making the occurence of overdosage of acetaminophen extremely high. In 2002, the FDA Advisory Committee estimated that up to 74% of overdosage ingestions were intentional, meaning that either doctors had prescibed the overdosage, or patients had intentionally, although unaware of the risks, self-medicated with too high a dosage.

The brand names of acetaminophen (paracetamol) include Anacin-3, Bromo Seltzer, Pediacare Children’s Fever Reducer Pain Reliever, Pediapap, Tylenol, and many others, including combinations of acetaminophen (paracetamol) with other chemicals in Actifed, Alka-Seltzer Cold and Sinus (and most Alka-Seltzer medications), Allerest Sinus, Anacin-PM, Bayer Select, Benadryl Allergy Cold, Comtrex Cold and Flu, Contact Cold and Flu, DayQuil Cold and Flu, Dimetapp Cold and Flu, Dristan Cold and Flu, Endocet, Excedrin Aspirin-free, Flextra, Midol Maximum Strength Menstrual, Midol Teen, Nyquil Cold and Flu, Robitussin Cold Cough and Flu, Sinarest, Sominex Pain Relief, Sudafed Sinus, Theraflu, and many other brand names. At this point in time, many patients are unwittingly taking acetaminophen in a number of forms daily, exceeding the safe dosage, and creating toxicity, in many cases. When combined with pain-relieving narcotic pain meds, the potential for acetaminophen toxicity is high. The affects of acetaminophen toxicity are usually not apparent immediately, but can be a cause or contributor to many common health problems over time.

The most common prescription pain relievers with a high dosage of acetaminophen are Hydrocodone and Oxycodone, usually known by the trade brand names as Vicodin, Norco, and Percocet. Oxy is now a familiar street term as well, as it has perhaps become the most abused street drug today in the United States. Our teenage children do not realize that they are damaging their livers, and the array of negative health problems in the future from this drug abuse will be incredible. In comparison, the use of simple heroin has few actual negative health effects other than the threat of overdose death. In 2002, strict warnings were routinely issued by medical doctors to not exceed dosage recommendations with Vicodin, or other forms of Hydrocodone, a synthetic form of codeine. One Vicodin tablet may contain up to 750 milligrams of acetaminophen. Doctors advised that there was a serious risk of overdose if patients took more than one or two of these higher dosage Hydrocodone and acetaminophen combinations. This taking of 2 pills, which was common, would means that the patient was taking 1500 milligrams of acetaminophen with one dose! Percocets, or other forms of Oxycodone, could contain up to 650 milligrams of acetaminophen. Drug companies told the prescribing doctors that patients should try not to exceed 4000 milligrams per day of acetaminophen! The reality of chronic pain is well known, though. These synthetic opioid medications have a very diminished effect with over 10 days of use. Chronic pain sufferers would resort to increasing dosages over time. After some time of use, it is believed that the high dosage of acetaminophen is probably the most effective part of the medication. Liver damage is expected, and the array of health problems associated with chronic liver dysfunction is dizzying. Of course, we all just ignore this fact, doctors and patient alike.

So let us do the math. The Merck Manual states that 7500 mg per day in a typical adult (not a small person) will result in acute liver toxicity, or acetaminophen poisoning. Now, with taking just 2 high dose Vicodans at at time, every 2-3 hours, at 1500 mg of acetaminophen per dose, a person with moderate chronic pain taking 5 doses per day is consuming what the Merck Manual states is acetaminophen toxic dosage for acute liver damage and serious consequences. Obviously, many patients were taking at least this amount, and many of these patients were smaller in stature, or had other contributing factors impacting liver function. Of course, over time, with chronic pain medication use, the liver function is expected to be overstressed and more susceptible to acetaminophen toxicity. The incredible fact is how the medical community, the government, and the public, especially those doing the deed, have remained so placid and unconcerned. We get so consumed by news of a natural disaster, terrorist attack, or common diseases, and yet a problem that is causing more deaths, and a lot more health injury, is treated so lightly. It could be that the pharmaceutical industry, with massive amounts of money spent on lobbying, advertising, payments to medical professionals and researchers, and domination of media advertising income, have succeeded in protecting the enormous profits reaped from this misguided treatment of chronic pain, and have thoroughly controlled public and professional perception, and enormously threatened public health, without consequence.

The response to the common overdosage of Vicodin, or other Hydrocodone prescription, with chronic untreated pain, led to the pharmaceutical industry heavily promoting another solution. Norco contains 10 mg of hydrocodone bitartrate, which is twice the dosage of standard Vicodin, but limits the amount of acetaminophen (paracetamol) to 350 mg per dose. Standard dosage often prescribes 2 Norco every 3 hours, though. A high dosage form of Vicodin, with 7.5 mg hydrocodone, was also made available, but this pill contains 750 mg of acetaminophen (paracetamol) per pill, and although dosage is not supposed to exceed 1 tablet per 3 hours and 5 maximum per day, chronic pain sufferers are well known to heavily exceed this dosage, and the reports of patients obtaining prescriptions from multiple doctors at once, or supplementing with illegally purchased hydrocodone (re: the Rush Limbaugh episode, where his housekeeper revealed that she was acting as Mr. Limbaugh's drug runner (or legal purchaser) for years, and Rush was found to be using as many as 30 Oxycontin per day, and utilizing perhaps 7 prescriptions, despite lack of evidence that he had a serious condition causing severe pain. His admittance of drug overuse pointed only to his pilonidal cyst, a hair follicle cyst near the anus, that is almost never left untreated with minor surgery when painful.) This example is only one of millions of chronic abuse of amazing overdose of narcotic pain medications with concurrent amounts of acetaminophen per day that is way beyond the maximum amount that the FDA Advisory Panel suggested came with high risk of liver damage in 1977.

The typical patient with chronic use of pain relieving medication, though, is not a drug abuser, but an ordinary person with a chronic pain, or subacute pain, that is not being treated properly, and instead “managed” with pain medications either prescribed, or obtained over-the-counter from the drugstore without need of prescription, or taking a combination of nonprescription and prescription pain medications. The increase in sales and prescription of pain medication in the last decade is quite dramatic in the U.S., and attracting concern from a number of quarters. Awareness of the consequences of this common type of pain relief is resulting in more and more patients in recent years exploring alternatives to pain managed, or masked, by drug use, and more and more turning to acupuncture and TCM medicine. A combination of acupuncture with physiotherapy (Tui na), herbal and nutrient medicine, correction of postural mechanics and habits that perpetuate tissue injury, and instruction in targeted stretch and exercise, provides an extremely effective alternative to these harmful practices of overconsumption of standard pain drugs.

Warnings of the associations between acetaminophen toxicity and the rising rates of asthma, COPD, allergic sinusitis/rhinitis and eczema

With health authorities speaking worldwide of a rise in the incidence of asthma, COPD, allergic sinusitis, and eczema over the last decade, many studies have been performed to determine the underlying causes of these now prevalent and serious disorders. Of all associations in large demographic studies of patient histories and potential causes, the increase in the use acetaminophen stands out.

Acetaminophen (paracetamol) is the non-steroidal anti-inflammatory (NSAID) medication most associated with asthma. Both asthma and allergic sinusitis (rhinitis), which is heavily associated with asthma, especially in young patients, have shown a significant association with acetaminophen use in large studies. A large study in 2010 by the University of Auckland, New Zealand, part of The International Study of Asthma and Allergies in Childhood (ISAAC), found that the most prevalent associations with prevalence of asthmatic symptoms worldwide were sales of acetaminophen (paracetamol), trans fats in food, and smoking prevalence in women (PMID: 20092649). Even air pollution, as measured by ambient particulate matter (PM), or soot, which has been blamed in recent years for increase in asthmatic symptoms, and generated bans on the use of fireplaces and wood stoves in cities such as San Francisco, was found to have little or no association with the prevalence of childhood asthma by the ISAAC study (PMID: 19819866). The increase in sales of acetaminophen were highly associated.

A 2011 report by the Akron Children’s Hospital Department of Pediatrics, in Akron, Ohio, and published in the medical journal Pediatrics (2011 Dec:1181-5), stated that: “The epidemiologic association between acetaminophen use and asthma prevalence and severity in children and adults is well established. A variety of observations suggest that acetaminophen use has contributed to the recent increase in asthma prevalence in children: (1) the strenght of association; (2) the consistency of association across age; (3) the dose-response relationship; (4) the timing of increased acetaminophen use and the asthma epidemic; (5) the relationship between per-capita sales of acetaminophen and asthma prevalence across countries; (6) the results of a double-blind trial of ibuprofen and acetaminophen for treatment of fever in asthmatic children; and (7) the biologically plausible mechanism of glutathione depletion in airway mucosa. Until future studies document the safety of this drug, children with asthma or at risk for asthma should avoid the use of acetaminophen.” There can be no more certain statement than this.

One particular aspect of the link between acetaminophen use and asthma, as well as chronic allergic sinusitis and eczema, is the depletion of our most important cellular detoxification pathway, the glutathione depletion in airway mucosa. The subject of glutathione may be further explored on a separate article on this website, entitled Glutathione Metabolism, restoration and balance. Since 1999, the sales of acetaminophen have increased dramatically, and these red flags concerning the liver toxicity and damage to the detoxification pathway resulting from acetaminophen use were ignored, as the increase in asthma, COPD, allergic sinusitis and eczema have now reached epidemic proportions, according to health experts.

How Acetaminophen (paracetamol) damages the liver, and how to correct this damage with herbal and nutrient medicine and acupuncture

Acetaminophen, or paracetamol, is a drug that is broken down in the liver, and this detoxification process may overstress the liver, as well as produce harmful byproducts that are very toxic. One byproduct of acetaminophen catabolism is N-acetyl-p-benzoquinoneimine (NAPQI), which if produced in very small amounts in the liver is mostly excreted in the urine. Whenever there is an appreciable amount of NAPQI, though, liver cells are harmed by the toxicity. As acetaminophen amounts increase in the liver, the liver is often unable to easily metabolize higher dosages, and the creation of NAPQI in relation to the level of acetaminophen rises appreciably. Each individual has a different capcity for liver function, and liver function in each individual may vary considerably depending on liver stressors at any one point in time. The more drugs consumed, and the more alcohol, the more stress is placed on liver function. While alcohol is commonly known as a liver stressor, there are over 900 drugs implicated in potential liver injury, or hepatotoxicity. Concurrent use of pain medication with acetaminophen and alcohol is very common. FDA withdrawal of drugs from the market have occurred more frequently due to evidence of hepatotoxicity than perhaps any other cause. Drug induced liver injury is responsible for over 5% of all hospital admissions. A common test for liver malfunction is an enzyme assay, but a finding of liver enzymes (transanimases) that exceed a maximum normal is not a requirement of a diagnosis of liver damage, and is only one of a number of objective tests. It is well known that a number of serious liver diseases and dysfunctions may be diagnosed despite the findings of normal liver enzymes in the circulation. The body adapts in chronic diseases. This finding of high liver enzymes in circulation is more applicable to acute changes and onset of liver disease and toxicity. Many cases of acetaminophen overuse involve chronic hepatotoxicity, which may be hard to detect with standard medical tests.

Liver damage, or hepatoxicity, may occur due to a number of mechanisms. Many chemicals, both drugs and environmental toxins, may damage mitochondria inside liver cells, decreasing cellular energy potential, and requiring an enormous increase in antioxidant and glutathione detoxifying capacity. Simple activation of some of the common pathways of breakdown of drugs, such as the P450 enzyme pathway, particularly the CYP2E1, have been shown to increase oxidative stress significantly, even under normal circumstances. With decreased cellular capacity and oxidative stress, accumulation of fats (e.g. cholesterol), which are broken down in the liver to create bile acids, occurs, and the term “fatty liver” is used to describe this condition, which is also highly associated with Metabolic Syndrome, or type 2 diabetes. Oxidative stress can also produce scarring, or sclerosis, of the liver channels, or hepatosclerosis. Both fatty liver and hepatosclerosis may lead to poor bile flow and excretion, and an accumulation of toxic bile acids in the liver. Bile acids are a family of acids, though, and some are created by other catabolic pathways. About a half of the cholesterol produced in the body (yes, almost all cholesterol is produced in the body, and not consumed in food) is used in bile acid synthesis. This is one reason why a finding of high cholesterol does not always mean simply that there is too much cholesterol leading to excess accumulation on the arteries. When hepatotoxicity occurs, backup of bile, accumulation of bile acids, ineffecient flow of bile, gallstone formation, and other problems may occur. Drugs that block expression of cholesterol and lipoproteins may also have a negative effect on this toxic condition.

An array of common problems are associate with hepatoxicity, and potentially to the overuse of acetaminophen, NSAIDS, and steroids. These include hepatitis (liver inflammation), cholestasis (impaired bile flow), steatosis (fatty liver), granuloma (accumulation of immune cells that surround toxins and form spherical masses), vascular lesions (injury to blood vessels), and neoplasms (tumors and cancer). Diagnoses of these problems is problematic, and most cases are only diagnosed when serious or life-threatening signs and symptoms occur. The smart patient wants to avoid these problems, and when they are suspected, to treat or prevent them from getting worse. A wide variety of liver problems means that a wide variety of treatments may be applicable. A comprehensive array of treatments may be administered at once with standard TCM therapies that include acupuncture and herbal/nutrient medicine, combined with targeted dietary changes. There is no single herb or nutrient that will clear all of these problems. Searching for the magic pill or silver bullet is not an intelligent approach. Seeking knowledgeable treatment and advice from a professional is sensible.

A number of research studies have proven that an array of herbs and nutrient medicines do reduce acetaminophen toxicity. The most well known of these remedies include the shisandra berry extract (wu wei zi), milk thistle extract (Silybum marianum, especially standardized silymarin extracts), N-acetyl cysteine, and other products that boost glutathione metabolism (see a separate article on this website). Acute toxicity may be treated with digestive charcoal. Research for decades, though, especially in China, has revealed that a wide variety of Chinese herbs reduce hepatotoxicity, and are hepatoprotective. Formulas of herbs that achieve a variety of beneficial effects related to the problems described above are, of course, much more effective in achieving resolution of hepatoxicity than specific herbs. Dosage is also important, as well as quality of herbal medication. Utilizing top quality professional products may be all important. Relying on heavily advertised nonprofessional products is often a ticket for failure. Other formulas have been devised in Traditional Chinese Herbalism, or Chinese Herbal Medicine, that are gentler and hepatoprotective, rather than clearing of liver tissue and cellular pathology. Stronger formulas have been devised when dramatic signs of bile stasis, or sclerosis, are evident. If the liver toxicity has advanced to jaundice, meaning that the bile is backed up into the bloodstream, even stronger and more specific Chinese herbs and formulas will address this problem efficiently. A patient needs to consult a knowledgeable professional.

How to know whether you may have liver toxicity or damage from pain medications

When suspecting that you may have liver toxicity, liver damage, or liver dysfunction, the array of presentations, and the variety of the extent of problems, presents no single clear picture. Liver toxicity does not have a binary outcome, or a simple toxicity or not toxicity. Being aware of the nuances that may occur with liver toxicity, liver damage, and liver dysfunction helps you to objectively assess your situation and determine if you should go to an expert and start testing. If the presentation does not warrant testing, you might still receive some simple treatment to reverse dysfunction, clear toxins, and prevent more serious problems. Complementary Medicine offers a wide variety of solutions.

There are a number of signs and symptoms of acute liver toxicity, and not all of these are evident with every patient. When liver dysfunction is severe and acute, jaundice may occur. Jaundice is a yellowish staining of the whites of the eyes and skin due to bilirubin, a component of bile, overflowing or backing up into the circulating blood. Most often, severe jaundice is due to excessive destruction of red blood cells (usually in the spleen as a result of infection and inflammatory destruction), but when normal amounts of bilirubin go to the liver, and the liver cannot process them, a more gradual and milder form or jaundice may occur. This will usually only be noticed as a slight yellowish tint to the whites of the eyes. Other classic signs of acute liver toxicity include nausea, inexplicable vomiting, loss of appetite, fatique, abdominal pain (usually under the right ribcage), a feeling of abdominal swelling or tightness, itchy skin, darker urine, pale or greasy stool (inability to breakdown fats), dark stool (blood), and joint pain.

If acute liver toxicity is suspected, blood tests that reveal problems include, but should not be limited to, liver enzyme assays (ALT and AST are the most common tested). Necrosis (tissue death) of hepatocytes (liver cells) in toxic injury usually results in the leakage of enzymes into the circulation. In chronic liver diseases and toxicity, though, the rise in liver enzymes may not be dramatic, and may not exceed the normally accepted maximum levels related to disease. The change in liver enzymes is most important in these cases, yet this is rarely assessed. ALT (alanin aminotransferase) is associated not with miotchondrial destruction, but cytosolic, and serum level only correlated moderately with liver inflammation. AST (asparate aminotransferase) correlates more with toxic damage. If the toxicity creates less dramatic cell death, or apoptosis, it is presumed that the liver cells sythesize less AST and ALT as they die. Studies have shown that one third of patients with hepatitis C have persistently normal ALT levels, despite the presence of inflammation. Patients with cirrhosis also often have normal ALT and AST. If liver toxicity is suspected, more tests than just the liver enzymes need to be assessed.

Blood tests should assess albumin (the main blood protein made by the liver), ammonia (a measure of how the liver is breaking down proteins and dealing with the byproducts, or converting the ammonia from proteins broken down in the gastrointestinal tract by bacteria into urea), bilirubin (breakdown byproduct of bile metabolism), INR (a blood clotting test - the liver produces key clotting factors), and AFP (alpha-fetoprotein, a sign of potential liver cancer). Abnormalities should be assessed with nuance. If a serious problem is suspected, a liver biopsy will be ordered, but if the problem is not so serious, the medical doctor might tell you that all is well, no serious liver disease. This does not mean the a milder toxicity does not exist. Checking the levels yourself, and comparing to past tests, is a good idea, or bring the tests to a Complementary Medicine physician to assess for more nuanced changes that might indicate liver toxicity.

If more serious acute liver toxicity is apparent, ultrasound or MRI may be warranted to assess evidence of fatty liver or liver damage is areas of the liver. A CT is sometimes used, but the amount of harmful added radiation from these tests is a problem. Radioactive dye in liver scans also do not directly expose one to active radioactive substance, but the scan adds radiation, and the dye is somewhat toxic, which is a consideration for many.

A wide array of signs may accompany acute or chronic liver toxicity. The most common early subtle signs are general feelings of illness, flu-like symptoms and body aches. These are experienced in the abscence of an actual flu or cold. Lack of interest in food is a classic sign of liver dysfunction, as well as difficulty digesting fatty or greasy foods. Other signs include inexplicable widespread and espisodic itching, increased easy bruising and persistent bleeding, upper GI bleeding showing as darkened stool, dull mental functions (short term memory lapses, trouble concentrating) from accumulation of toxins in the brain, increased sensitivity to medications (drugs don't metabolize and clear as fast, with higher levels accumulating in the blood), and gallbladder discomfort (episodes of inexplicable nausea, fullness or tenderness under the rib cage, indigestion after eating), are all signs of chronic liver toxicity. Chronic liver cirrhosis may also cause immune dysfunction, intestinal infection, and lead to impotence, chronic kidney dysfunction, and osteoporosis (poor production of the hormone Vitamin D3 by the kidney regulating calcium in the body, or poor conversion of cholcalciferol prohormone to the prehormone calcidiol). Anemia may also be present. Since the liver is the most active detoxifier of the blood in the body, liver dysfunction may also cause increased systemic toxicity and accumulations of environmental toxins, such as heavy metals, as well as disseminated microbial infections, such as candida. Patients with chronic liver toxicity will be much more affected by alcohol, as the liver metabolism wants to process this carbohydrate acid quickly. This is the reason why some people will feel funny when drinking alcohol and consuming pain meds with a high dose of acetaminophen.

No matter what the degree of liver toxicity, a professional Complementary Medicine physician, such as a Licensed Acupuncturist and herbalist, if knowledgeable, can help resolve and restore. While it is true that liver dysfunction and toxicity may make it hard to break down even some herbal chemicals, this just shows that perhaps patients shouldn't self medicate with herbs in these situations. Monitoring and professional guidelines are very important, and are closely followed by a Licensed Acupuncturist, who receives a standard 4 year graduate medical school training, usually heavily tilted toward herbal medicine. Standard medicine, on the other hand, meaning medical doctors, have little or no training and education in herbal medicine. While medical doctors may be smart, one needs to be somewhat skeptical of their professional training, knowledge, and guidelines in this area.

Why NSAIDS, such as aspirin and ibuprofen, have inherent risks and adverse side effects with long-term use

NSAIDS, or non-steroidal anti-inflammatory medications, comprise a large list of common pain medications. Aspirin was the first modern pharmaceutical drug synthesized and heavily marketed. It is an alteration of an herbal chemical, salicylic acid (salicin), most commonly derived in Europe from the bark of the white willow tree (salix is Latin for willow tree). In the 1800s, a medicinal extract of white willow bark was frequently used to treat pain and inflammation. Salicylic acid functions as a plant hormone, and is found in a variety of Chinese medicinal herbs, such as ginseng (Ren shen), and Isatis (Da qing ye). Salicylates are a related class of herbal chemicals found in such Chinese pain relieving herbs as Yan hu suo (Corydalis) and Dan Shen (Salvia miltiorrhizae). Salicin from white willow bark was isolated and altered to form a quick acting salicylic acid, which became aspirin, the first pharmaceutical NSAID.

Another acid, iso-butyl-propanoic acid, commonly called ibuprofen, is now a more common NSAID than even aspirin, marketed under dozens of trade names, such as Advil, Motrin, Nuprin, Naprosen, Emuprofen, etc. These drugs, and the classes of drugs called Naproxen (Aleve, Naprosyn), and COX-2 inhibitors (Vioxx, Celebrex, etc.), all work by inhibiting enzymes that convert arachidonic fatty acids to PGE2 (prostaglandin E2) or PGH2, and to thromboxane A2. In the inflammatory process, our bodies create a number of inflammatory mediators from essential fatty acids, and PGE2 regulates some of the inflammatory processes associated with pain, such as swelling and decreased local circulation. Thromboxane 2 controls platelet aggregation, or the clotting of blood, and an anti-thromboxane 2 effect enhances circulation. Unfortunately, inhibition of PGE2 with aspirin and other NSAIDS also inhibits all prostanoid synthesis, which is an undesirable effect overall. When all prostanoids are inhibited, our inflammatory system, a key aspect of our immune responses, is not able to sufficiently clean up chronic tissue problems, and eventually, such tissues as arterial linings and stomach membranes will suffer. Hence, these NSAIDS create increased ill health and risks with cardiovascular disease and gastrointestinal disease, and may cause or contribute to strokes, heart attacks, bleeding ulcers in the stomach and small intestine, and a host of other problems. While inhibition of PGE2 relieves symptoms of pain and swelling, one of the enzymes inhibited, prostaglandin E synthase, is also involved in glutathione metabolism, and an inhibition of glutathione metabolism may have devastating consequences, since this is our body's main cell detoxifying mechanism (see the article entitled Glutathion Metabolism, restoration and balance on this website).

Inhibition of PGE2 has other consequences as well. PGE2 functions to decrease gastric acid secretion, increase gastric mucosal secretions, contract the uterus, contract gastrointestinal smooth muscle, inhibit lipolysis, and increase autonomic neurotransmitters. The potential adverse effects with long-term excess use of NSAIDS thus include gastric hypofunction, poor digestion, constipation, weight gain, affects on fertility, and numerous symptoms of autonomic dysfunction. Of course, a short course of NSAIDS to relieve pain is harmless and without problems. This is what the drug is intended for. On the other hand, long-term use, excess dosage, and combination with acetaminophen, comprise many adverse effects. The intelligent patient and physician will utilize some more conservative strategy with the treatment of chronic pain, and even with subacute pain, since the use of pain relievers after a short number of days is probably not wise. When pain relief is required, a short course of pain medication, for a week, may be necessary, but immediate use of conservative care physiotherapies, acupuncture, and herbal medicine is highly recommended to make sure that the pain is not substantial enough to require pain medication longer than a week.

Discouraging of safer alternatives in NSAID use

Another plant chemical that may be considered in the class of NSAIDS is DMSO, dimethyl sulfoxide, which is mainly derived from seeds, and is a much used polar solvent and ligand. DMSO was found to be able to penetrate the skin and carry other chemicals more deeply into the tissues, and disseminate rapidly in the body, making it an excellent potential carrier for other chemicals in medicine. Research after World War II also uncovered that fact that DMSO was a potent anti-inflammatory. DMSO was first synthesized for commercial uses in 1866 in Russia, and is frequently used as a polar solvent in various chemical reactions involving salts and esters. In chemistry, it is used as an extractant in biochemistry and cell biology. In manufacturing, DMSO is used as a paint stripper that is safe, and thus widely used instead of dangerous chemical paint strippers. In 1963, the University of Oregon Medical School discovered that DMSO could penetrate the skin barrier and other membranes safely without damaging them, and carry other compounds into the biological system. They also found that it was a strong analgesic and antioxidant, and thus could be a useful component to carry anti-inflammatory NSAIDS or herbal chemicals into the body. This research led to a conclusion that DMSO was a type of NSAID, or non-steroidal anti-inflammatory, that comprised a new class of NSAIDS. The reponse from the pharmaceutical industry was to strongly urge the FDA to do long-term studies to judge efficacy and safety. These long-term studies have apparently never stopped, as the use of DMSO was never approved medicinally by the FDA, without any evidence of harmful effect, other than a bad smell, and the prescence of a garlic like taste in the mouth.

In 1978, the reknowned Cleveland Clinic found that DMSO exerted significant pain relief to a majority of 213 patients with painful genitourinary disorders. They recommended DMSO for all inflammatory conditions not caused by infection or tumor, especially when the pain symptoms did not respond to conventional pain medications. Since then, DMSO in the United States is only approved by the FDA for interstitial cystitis pain and urinary frequency and urgency. DMSO is a restricted chemical in the United States, and purchase of DMSO for medical purposes is very difficult. In fact, purchase of DMSO for other purposes became difficult in the United States. On the other hand, purchase of DMSO for medical use, stripping of paint, and a general solvent in most other countries is not a problem. Animal studies showed that treatment with DMSO within one hour of spinal cord injury could prevent paralysis. One would think that this DMSO would be utilized. It is not. In veterinary medicine, DMSO is used as a liniment in combination with other medicinals, including herbals, and is very safe and effective. In the United States, the pharmaceutical hold on government has been so tight that DMSO is still not used at all in human treatment. The toxicity of DMSO has been confirmed as very low, and the dosage needed in topical application is very small. Instead, a metabolite of DMSO, MSM, or methylsulfonylmethane, is a widely used component of both topical herbal medications, and oral herbal and nutrient formulas. Unfortunately, MSM is not a highly polar solvent, and much less effective as a reactive, ligand, and carrier. The anti-inflammatory effects of MSM are slight compared to DMSO.

One can only speculate as to the number of deaths from NSAID overuse that could have been prevented if DMSO was approved and utilized correctly in the United States.

Besides safer herbal and nutrient chemicals for pain relief, simple mechanical means of pain relief such as targeted heat, electrical feedback, and laser phototherapy have been discouraged in the common practice of pain relief despite proof of efficacy. An example of such alternatives to pain medication is seen in the development of the Pain Free Socket by a young woman who started her research and development in high school. Katherine Bomkamp was inspired to find an alternative means to relieve phantom pain for military veterans with amputations after accompanying her father, a disable Air Force veteran to Walter Reed Army Medical Center and hearing the numerous waiting room stories of intense phantom pains from veterans with amputations and prosthetics. While Ms. Bomkamp was not interested in science per se, she became very interested in finding an alternative to the chronic prescription of barbituates and antipsychotic medications prescribed for this neuralgia. She knew from her own experience that the application of heat relieved pain, and proceeded to work with local university engineers to create a prosthetic device that would stimulate peripheral pain receptors with heat to redirect the pain reaction in the brain, utilizing the concept of thermal biofeedback. Today, she has patented her device and awaits FDA approval. Prosthetics manufacturers are interested in this design as a prototype for more sophisticated devices that may dramatically decrease the dependence on medications that have limited effect and harsh side effects with chronic use. The impetus for such design in standard medicine is nonexistent, and it took a concerned high school student to pursue this simple means of thermal biofeedback. Why? Because the funding for medical research promotes lucrative pharmacological solutions only.

Corticosteroid injections for pain and topical pain relievers: Another health risk with little awareness by the public

Corticosteroid therapy, a treatment to control the inflammatory processes to ease joint pain, decrease asthmatic bronchiole or tracheal swelling, decrease skin inflammation, or to decrease undesirable immune response in various autoimmune disorders, has long been considered an effective but potentially harmful means to decrease symptoms that are threatening to the patient. The high risk of serious side effects and long term damage to the hormonal, or endocrine system, has prompted most authors of medical texts to recommend that other therapies be tried before resorting to this type of therapy. Unfortunately, since the medical field has increasingly moved away from simpler conservative therapies to a greater dependence on new pharmaceutical approaches, and the pharmaceutical industry has not generated effective medications to treat inflammatory disorders, the use of corticosteroids has become routine rather than the treatment of last resort.

The patient should consider and discuss potential side effects with the prescribing doctor when considering this treatment and considering possible alternatives that are less potentially harmful. The National Institute of Health (NIH) gives these side effects as common for patients taking higher doses, and potential for all patients: stomach irritation, muscle weakness, increased blood pressure, diabetes, fluid retention and weight gain, easy bruising, delayed wound healing or tissue repair, glaucoma, decreased calcium absorption and osteoporosis, and decrease in the body’s natural production of corticosteroid hormones. In addition corticosteroids, even applied topically, have consistently shown to cause birth defects in laboratory animals. Corticosteroids may also lower your resistance to infections and make infections hard to treat. After prolonged use there is usually a prolonged time of adjustment, lasting up to a year, with side effects of muscle and joint pain, reappearance of disease symptoms, shortness of breath, tiredness or weakness, headaches, nausea, dizziness, fainting, abdominal pain, low fever and loss of appetite.

Since there are a number of corticosteroid hormones produced naturally in the body, the taking of a particular synthetic corticosteroid will inhibit various other natural corticosteroid functions. The body utilizes corticosteroid chemicals to regulate and control many processes in the body. Depending upon the patient’s health history, this effect could be dramatic or go unnoticed. In addition, since the hormonal or endocrine system operates on an elaborate feedback mechanism, and many hormones are converted to other hormones as needed in this system, the other steroid hormones in the body will potentially become deficient over time. This is the reason that diabetes is a common side effect, since the pancreas is an endocrine gland and insulin and glucagons are steroid hormones. In addition, a study at the Dept. of Pharmacy and Therapeutics at the University of Pittsburgh (PMID:16901792), found that: “Hyperglycemia occurs in a majority of hospitalized patients receiving high doses of corticosteroids.” This effect is seen in corticosteroid injections as well as oral dosing.

The most common type of corticosteroid, the asthma inhaler, has acquired a number of warnings from the FDA in recent years. Many of the inhalers now prescribed combine long-acting beta-adrenergic inhibitors with corticosteroids to increase the effectiveness. Inhibiting beta-adrenergic response quiets the bronchial spasms, while direct corticosteroid application inhibits the inflammatory swelling of the bronchioles. Government warnings state that even though these medications may decrease the frequency of asthma episodes, they may make episodes more severe, and in some patients, these severe episodes have ultimately ended with a fatal asthmatic event. Studies have shown that patients have increased the frequency of use of these inhalers, increasing the risk of severe episodes. This points to the fact that for many patients, frequency of asthma attacks have also increased with use. The physiological reason that the asthma has worsened with use is that the body's natural hormone reactions are being inhibited. A new type of asthma medication, Alvesco, was created to help with the problem of adrenal damage from chronic use of asthma corticosteroid albuterol. This new version is designed to inhibit release into full circulation by requiring a metabolic step to activate the corticosteroid. Alvesco was created due to clinical studies showing widespread injury to adrenal health with chronic use of corticosteroids.

The effects of long term use of corticosteroid therapy has been well documented. For example, studies at the Albert Einstein College of Medicine in New York (PMID:1682792) showed that: “Long-term low dose corticosteroid use may reversibly decrease B-cell counts and specific antibody responses.” While this may produce desirable effects with specific symptoms, it may also produce many undesirable effects on the whole immune response in your body, with increased risk of other diseases and infections. The risk of tuberculosis dissemination and fungal overgrowth, such as candidiasis is well documented. The medical faculty of the University Hospital Clinics in Barcelona Spain (PMID:8941496) concluded that: “Osteoporosis is one of the most serious adverse effects experienced by patients receiving long term corticosteroid therapy.” Inflammatory bowel conditions and relative lack of weight bearing exercise may increase the risk of corticosteroid induced osteoporosis, and postmenopausal women are particularly at risk. The most rapid bone loss occurs in the first 12-24 months after starting corticosteroid therapies (PMID:10769436). Steroid use has been found to cause fat cell enlargement resulting in blockage of veinous blood return in bone and leading to bone deterioration and small fractures (Univ. of Washington Radiology, www.rad.washington.edu/maintf/cases/unk54/answers.html). Cataracts are also a frequent side effect. The incidence of cataracts in the normal population is 0-4%, but in chronic users of steroid therapies at moderate dose, 30-40% are found to get cataracts, and over 80% will acquire cataracts at high long-term dosage (National Institute of Neurological Diseases and Blindness, NIH grant, Washington Univ. School of Medicine, St. Louis Mo.)

Studies have also linked chronic use of inhaled corticosteroids to such common problems as snoring and sleep apnea. A 2002 study at the University of Wisconsin School of Medicine and Public Health, cited below, found that there was an association of high risk for obstructive sleep apnea for patients using inhaled corticosteroid medications habitually for asthma control. Obstructive sleep apnea also has a high association of risk in cardiovascular medicine for heart attacks and strokes. While simply stopping the use of coricosteroid inhalers is not possible for most asthma patients, the decrease in the chronic use of these corticosteroids is possible by utilizing Complementary Medicine to calm symptoms, promote healing of the bronchiole membranes, and improve immune responses over time.

Does a regimen of calcium supplements with vitamin D prevent this osteoporosis? A large study by the Womens’ Health Initiative in 2005 showed little if any effect from this regimen in prevention of osteoporotic fractures in menopausal women, yet a military study showed that large dosage supplementation decreased incidence of stress fractures in young healthy women undergoing strenuous training. This seems to suggest that utilization of the supplements is the key, with hormone deficient women showing problems in utilizing calcium supplements. This is because calcium is the most regulated nutrient in the body.

Are patients on corticosteroid therapies being monitored for long term side effects? There are few reports of systems of monitoring for side effects after administering these therapies. There are few reports of studies on the follow up of corticosteroid therapies, especially in the United States. In Australia, a study was conducted at the Universtity of Tasmania School of Pharmacy (PMID:10886467) and concluded from a randomized review of 212 patients consecutively admitted to a large hospital and receiving long-term corticosteroid therapies, such as inhalers, oral meds, or injections, that less than 20% of these patient were being tested for bone density decreases and less than half had had blood glucose tests administered in the last year. There is little data to show any follow up in the U.S.

The use of steroids in the United States, despite long years of warnings from research, has continued to increase. Even over the counter products, including beauty products, now routinely use synthetic steroids without having to print warnings. A 2010 article in the New York Times outlined how skin lighteners have brought many patients to the medical clinic with alarming problems. The article outlines how steroids added to the creams upset the immune and hormonal responses in the body, producing thin skin, bruising, stubborn acne, and other side effects. The synthetic steroids are listed as ingredients, but there are so many different chemcicals now that the names on the ingredient lists mean nothing to the consumer. Clobetasol propionate is one of the steroids mentioned in the article, which is a potent synthetic steroid, but the label only states that the product should be used only as directed by a physician, even though it is sold over the counter. Counterfeit health and beauty products are also becoming common, and use of synthetic steroids in these products is now common to increase immediate effects. The consumer in the United States may be taking an array of low dose synthetic corticosteroids unwittingly.

Cortisone shots for the relief of joint pain

One of the most prevalent uses of synthetic corticosteroids is the cortisone injections commonly used to treat joint pain. An October 28, 2010 article in the New York Times Health section reviews the history of these injections, and new light shed on the efficacy versus harm from cortisone injections revealed in a British Lancet article on 45 randomized trials of cortisone injections and long-term outcomes. It appears that, while these injections bring short term partial relief of pain to about 63% of patients, the vast majority of the patients studied had worse long-term outcomes after 6 months than those that received no treatment. The patients receiving cortisone shots also had a 63% increased incidence of relapse, and multiple cortisone injections produced a 57% worse outcome than a single injection. The senior author of the study, Bill Vicenzino, the chairman of sports physiotherapy at the University of Queensland in Australia, stated that many orthopedists routinely prescribed cortisone injections as a wait-and-see therapy, to see if the injury healed on its own after 6 months, with temporary relief provided by multiple cortisone injections, but that it appeared that the cortisone injections impeded the healing. This type of therapy often supersedes actual physiotherapy on the injured tissues. The study authors stated also that the injections were warranted because the stated diagnosis was usually tendinitis, implying that there was an underlying inflammatory problem, whereas in reality, there was a degenerative tissue problem in most cases. In other words, the therapy of choice was dictating the diagnosis. This is common practice in medicine today, and too often, this is because the insurer only pays for the cortisone injection, and routinely rejects actual tissue therapies, and even testing to determine the actual diagnosis, such as an MRI. You may click on this link to read the article: http://well.blogs.nytimes.com/2010/10/27/do-cortisone-shots-actually-make-things-worse/?src=me&ref=general

Not only pain medication alone, but the combination of pain medications and other commonly prescribed pharmaceuticals, as well as alcohol, are now creating a significant number of deaths from precription drug combinations

A February 13, 2011 article in the New York Times reveals that many of our serviceman coming back from Iraq and Afghanistan have died from taking the prescribed combination of drugs to treat their pain and post-traumatic stress disorders. To read this article, google: for some troops new york times. The article, written by James Dao, describes how a combination of psychiatric drugs and narcotic pain medications with acetaminophen are “increasingly linked to a rising tide of other problems, among them drug dependency, suicide, and fatal accidents - sometimes from the interaction of the drugs themselves.” To link to this article, click here: http://http://www.dispatch.com/live/content/national_world/stories/2011/02/13/ Another notable example in the news include the death of the actor Heath Ledger, who was taking a prescribed combination of pain medications and antidepressants and died from drug toxicity. This problem, largely ignored and hidden from public view, and rarely acknowledged in hospital reports, is now being recognized as a growing and serious threat to public health.

Abuse of prescription drugs for recreational use is a very common problem now, and treatment for abuse of prescription drugs now accounts for a fifth of all treatment admissions in some states, according to the National Drug Intelligence Center. The most widely abused street pharmaceuticals in 2000 were Xanax (a benzodiazepine), Oxycontin (narcotic pain medication), Valium (another benzodiazepine), Dilaudid (a narcotic pain medication), Methadone, Codeine, and amphetamine. The supposed war on drugs has apparently not decreased drug use in the United States, but has created a new market for pharmaceuticals that treat pain, substituting synthetic drugs for natural drugs. These synthetic drugs not only have a similar risk of overdose and withdrawal symptoms, but come with a large number of potential side effects and adverse health effects that their natural counterparts did not produce. The withdrawal symptoms for benzodiazepines are similar to those noted with barbituates and alcohol, with pain, tremor, vomiting and sweating, and account for their addictive street nature. Benzodiazepines make the effects of alcohol stronger, as well as some narcotic pain medications, and warnings about these drug interactions go with these drugs. This is the reason why these drugs are popular on the street, though, and potentially, many prescription drug users are taking these same combinations. The National Institute on Alcohol Abuse states that a combination of alcohol and lorazepam (a benzodiazepine anti-anxiety medication) may result in depressed heart and breathing functions.

Alcohol may have a significant effect on the metabolism and concentration of pain medication as well. The National Institutes on Alcohol Abuse and Alcoholism of the National Institutes of Health reports that alcohol-medication interactions may account for at least 25 percent of all emergency room admissions, with an unknown number of less serious interactions unrecorded or unrecognized. Alcohol may alter the bioavailability of pain medications by competing for enzymes in the liver that metabolize the medication, making more of the drug concentrated in the body, or increasing its effective dose, and harmful effects. Chronic alcohol use, on the other hand, may increase the metabolizing enzymes and result in faster metabolizing of pain medications, making them less effective for pain relief, and resulting in the taking of higher dosages to relieve pain. Alcohol may exacerbate the stomach bleeding and irritation, as well as the inhibition of blood clotting, that occurs with aspirin and other pain medications. Aspirin and other pain relievers may also heighten the effects of alcohol, impairing judgment, and resulting in improper dosing.

Increased use of acupuncture, herbal and nutrient medicine, and effective physiotherapies, for relief of pain, especially chronic pain, will reduce the problems associated with the overuse of pain medications. A society that relies less on pharmaceutical pain management may have less of a problem with abuse of these medications in the future, and less of a problem with harmful and dangerous interactions with other drugs and alcohol.

The proof that acupuncture and herbal medicine does have sufficient evidence-based effects to treat chronic inflammatory conditions, and other medical condition that cause pain

Such a large number of scientific studies, both physiological, and clinical human trials using randomized placebo controls, now exist, that it is unlikely that any patient is now unaware of the proof of acupuncture in relieving of pain. The impression that acupuncture only provides temporary relief of pain, though, has become a mantra of standard medicine, despite a large amount of evidence to the contrary. Acupuncture is proven to exert a wide array of physiological effects, promoting endorphin pain relief as well as improving circulation, modulating inflammatory mediators, stimulating neuroendocrine effects, and improving many homeostatic mechanisms that our bodies use to effect tissue repair. The proven physiological effects of acupuncture are very broad. One of the key effects in pain relief, though, is the modulation of inflammatory mediation to promote improved tissue repair and maintenance, and achieve less stimulation of pain receptors with unhealthy concentrations of inflammatory cytokines in chronic painful conditions.

A growing body of evidence from scientific study is confirming not only that acupuncture has proven efficacy to treat chronic inflammatory conditions, but how this needle stimulation works. Acupuncture is difficult to assess under the double-blind placebo-controlled conditions used to prove efficacy of corticosteroid pharmaceuticals, yet has been held to this standard. Creating an acupuncture placebo is problematic, and blinding both the administering physician and the patient to this so-called placebo versus real acupuncture has been a challenge. Acupuncture, in effect, has been held to higher standards of proof than any other manual therapy. Despite this, the NIH and WHO have reviewed evidence over decades and long ago declared that acupuncture is a proven evidence-based therapy for many chronic inflammatory conditions. Meta-analysis since then has shown that success in human clinical trials has been demonstrated in the treatment of rheumatoid arthritis, bronchial asthma, pruritic dermatosis, carpal tunnel syndrome, and other inflammatory disorders in humans and animals (SCOGNAMILLO-SZABO, BECHARA, 2001). Specific trials in recent years have confirmed the efficacy of acupuncture treatment on allergic rhinitis, bronchial asthma, eczema, rheumatoid arthritis, and other chronic inflammatory disorders (TOWNSEND et al 1999; TUMACHI 1999, CASIMIRO et al 2002, STERUER-STEYA, RUSSUB, STEURERC, 2002; BIELORY, HEIMALL, 2003, MADSEN et al 2003; MCCARNEY et al 2004). Each year clinical study is advancing and producing greater proof of the efficacy of acupuncture.

How does acupuncture control chronic inflamamtory conditions? Since the inflammatory response involves a complex set of highly orchestrated events in the body, with a cascade of chemical mediators insuring a highly regulated and modulated effect, this is a difficult question to study. The initial response to tissue injury and disease is largely controlled by the hormone cortisol, which is constantly produced mainly by the adrenal glands in a controlled diurnal cycle. Many health problems, especially hormonal imbalances, can adversely affect the diurnal cortisol levels and responses. Corticosteroids are synthetic chemicals that mimic this hormonal inflammatory mediator. There are many other inflammatory mediators in the body besides cortisol. Prostaglandins and interleukins are inflammatory mediators that are inhibited by non-steroidal anti-inflammatories. The problem with these pharmaceutical approaches is that when the whole cascade of inflammatory mediators is not addressed by the therapy, and that severe inflammatory dysregulation can occur, with disastrous results. Since the inflammatory process is a beneficial process in the body, evolved to repair and maintain healthy tissues, inhibition of a part of the process can produce unwanted results. The trials of malpractice and medical injury concerning the anti-inflammatory COX2 inhibitor, Vioxx, revealed that chronic use of this medication resulted in perhaps 50,000 deaths related to inflammatory dysregulation. The promise of acupuncture is that is may stimulate the whole natural cascade of inflammtory mediators in the body, and thus avoid these dangerous and unwanted side effects.

A 2005 study on animals at University Medical Schools and Veterinary Schools in Sao Paulo, Brazil, (Szabo et al, Sao Paulo State University and University of Sao Paulo, Faculty of Medicine, funded by ELISA and FAPESP), investigated the more specific effects of inflammatory modulation with acupuncture. Previous studies had demonstrated that acupuncture significantly suppressed neutrophil migration to the site of induced inflammation in the peritoneal cavity of study animals. Neutrophils are white blood cells that are the main immune reaction to acute infection and inflammation, and the peritoneum is the lining of the abdominal cavity. It was found that this acupuncture effect was not mediated by corticoid adrenal hormones, because a drug that blocked the corticoid receptors, RU-486, did not interfere with the immune response. Three cytokines, or inflammatory mediators, tumor necrosis factor alpha (TNFalpha), interleukin-1 beta (IL-1beta), and interleukin 10, were measured. It was found that acupuncture stimulation from just 3 needles distally placed, significantly inhibited just the interleukin-1beta, an important cytokine that stimulates neutrophil migration in the inflammatory complement system in humans. The researchers found that acupuncture stimulation exerts a modulatory effect on inflammation, and that specific effects are probably also tied to specific acupuncture locations on the body. In this study, the sites were between the eyebrows, at the lumbosacral junction, and near the anus. As with all such studies, the choice of acupuncture points and stimulation was designed for simplicity, and was probably less effective than many clinical acupuncture treatments.

The implications of this study, and numerous other scientific studies of anti-inflammatory, or inflammatory modulation effects of acupuncture, are that acupuncture stimulation is now proven to have an array of effects that modulate chronic and acute inflammatory states, and that these various effects stimulate an improved natural response in the body to inflammation. These studies also imply that various types of point selection and stimulation techniques are proven to have specific effects. In short, the empirical evidence collected over centuries in China concerning the application of acupuncture are proving true, based on modern laboratory measurement and modern scientific method.

In addition, a long history of myofascial trigger point needling is documented in TCM texts and clinical practice. Historically, this was called A shi needling, translated as “that’s it“, meaning that the patient indicates to the physician that they found the trigger point. Other terms used in historic literature also apply, such as trail needling, where the physician asks the patient where the trigger point symptoms radiate, and uses another needle in this trigger point along the dermatome or myotome. The acupuncture point locations are described as points along meridians and channels, as well as local points, and empirical points. While the public has been led to believe that acupuncture is limited to the shallow points noted as the main 365 point locations along 12 meridians, the TCM literature has much description of 6 types of meridians, with shallow to deep point locations that are determined by palpation, anatomy and triggering of a response (de qi). The types of meridians include broad tendon, ligament and fascial meridians that correspond to modern dermatomes and myotomes, as well as meridians that are described as a narrow line of points related to organs and the referred pain patterns of organ pathology. These referred pain patterns are analogous to the modern systems of dermatomes, myotomes, and referred organ patterns in the body, but predated the modern scientific theories by thousands of years. The use of myofascial trigger point needling is becoming widely accepted in standard medicine today as well, pioneered by the great Dr. Janet Travell, and documented by her colleague Dr. Simon. The acupuncture profession provides teaching of both the classic and modern theories and techniques. The scientific studies of myofascial trigger point needling and stimulation, as well as manual release, active release techniques, and even neuromuscular reeducation and other mind-body techniques researched in recent years directly applies to the practice of acupuncture and TCM.

These various acupuncture and physiotherapy modalities that are now extensively studied, undergoing randomized clinical human trials, and are proven, are also potentially combined in TCM practice with other proven treatment modalities that provide pain relief and resolve the underlying causes of pain. Anti-inflammatory effects of Chinese herbs are the subject of numerous well-funded studies and clinical trials in the United States, as well as China, many European countries, Japan, Australia, Brazil, etc. One only needs to go the U.S. Natiional Institutes of Health Pub-Med database to access many of these scientific studies. The important points we see elucidated in herbal studies are that the effects are dose dependant, that the choice and quality of herbs are important, and often that the extraction methods are important to achieve the correct chemicals. The way to insure that these objectives are achieved is by utilizing professional herbalists and their professional products. Most of these highly trained professional herbalists in the United States are Licensed Acupuncturists.

The key point when examining scientific evidence of the anti-inflammatory effects of acupuncture and Chinese herbs is the difference between the use of steroidal and non-steroidal synthetic medicines and the effects of acupuncture and Chinese herbs. The pharmaceutical approaches are specific and allopathic, meaning that the chemicals are designed to alter specific mechanisms in the inflammatory cascade. Acupuncture and Chinese herbs have been shown to have similar effects, but in a modulatory and varied manner, stimulating areas of the complex inflammatory cascade that may not be working efficiently due to some health problems in the body. The chance of side effects with the latter approach are slim, and the possibility of restoring the patient metabolisms are great. The endproduct of therapy should be a healthier immune system with Complementary Medicine, whereas the chronic use of synthetic corticosteroids has been found to have negative effects on the whole system, especially in producing adrenal insufficiency, which would negatively impact the ability to respond to future inflammation and infection. As we see from the studies cited above, the use of NSAIDS, especially the ubiquitous acetaminophen, which is also found in almost all narcotic pain medication, also has a deleterious effect on the immune responses, linked to rising rates of allergic asthma, sinusitis and eczema. This is not to say that standard treatment is discouraged, as modern allopathic treatments may have a strong and dramatic effect, but a thoughtful assessment of risk versus benefit will bring the intelligent doctor and patient to the conclusion that thes modern allopathic treatment should be used only when needed, and with limited courses, not chronic dependence.

Integrating care with Complementary Medicine provides the patient with safe, effective, and problem-resolving therapies, and reduces the dependence on prolonged therapy and drug dependence. Effective integration of the many treatment modalities of Traditional Chinese Medicine (TCM) may speed recovery and repair of tissues, as well as adaptation to chronic pain. Shortening treatment time with integrative medicine will both allow the patient to get back to work and reduce the overall expense of treating pain and injury. Acupuncture and Chinese herbs, as well as the direct physiotherapies (Tui na) may also be varied for each patient and treatment, producing individualized effects that the physician can choose in response to a changing condtion of the patient. The last significant advantage of the acupuncture and Chinese herbs is that the treatments can also be expanded to stimulate improved adrenal and immune function, producing future indirect benefits for the patient. The main side effects of acupuncture, herbal and nutrient medicine, and TCM physiotherapies, is improved overall health and prevention of many common health problems and diseases, as well as future injuries that result from chronic tissue problems and degeneration. Most injuries result because of an unhealthy focal tissue pathology that leaves the patient more vulnerable to injury with mild to moderate trauma.

Patient choices in the treatment of inflammatory disease

What are the considerations when discussing this type of therapy and what are the more conservative therapies that you can try? Risk versus benefit and lowering dosage are important considerations that should be included in your discussion. Monitoring for serious harm should be adopted on a schedule. The ultimate decision on whether to take these medications always lies with the patient. Never abruptly stop corticosteroid therapies, because the body needs to respond by starting to increase the natural production of these hormones. Safer conservative therapies can be tried and you can see for yourself whether you are making progress with these therapies. Scientific study has confirmed the efficacy of both herbal medicines and acupuncture in the role of inflammatory regulation and modulation, but the best approach is often to combine a variety of therapies to specifically address both the symptoms and underlying causes of chronic inflammatory and rheumatic conditions. This includes herbal prescription, improved diet and lifestlye, dietary supplements, physiotherapies, and acupuncture. The expertise and ability of the therapist administering these therapies is all important, as well as the attention of scientific study and evidence-based medicine. Herbal therapies, acupuncture, and physiotherapies are complicated subjects and there is much variation in the outcome depending on the skill of the practitioner. The choosing of the Licensed Acupuncturist if often very important, especially in more difficult diseases.

Choice of herbal medicine to treat chronic inflammatory and rheumatic conditions is also important. Many patients are swayed by internet sites that present herbal information and promote products with outlandish claims of benefit. Since the herbal industry is unregulated, commercial products should not be trusted for serious medical problems. Professional herbalists have access to products that are genuine and tested, since professional herbalists are much more demanding and educated in herbal science than the general public. These professional products may cost more than the discount products that are highly advertised, but this quality is essential to the cure. Physiotherapies may be very important in the overall treatment of inflammatory rheumatic conditions, but may be administered by therapists that have received only a few months of training. Hospitals and clinics often choose to hire the less trained physiotherapists for ‘therapeutic massage’. On the other hand, a TCM physician, or Licensed Acupuncturist, may have advanced training in physiotherapies, and be able to apply this training better, due to the years of advanced education in pathophysiology received in the TCM medical school. Physical therapists are well trained but often emphasize only rehabilitative exercise rather than soft tissue therapy and passive manipulation. The TCM physician may or may not have advanced training in physiotherapy, called Tui Na in China, and this too should be a consideration when choosing an acupuncturist. Acupuncture outcome, too, is completely dependant on the skill of the practitioner. While the act of needle insertion is simple, the obtaining of a response is a subtle and complicated process that depends on both the manual skills of the acupuncturist and the attention to the responses of the individual patient to the needle manipulation.

Hopefully, you can arrive at a course of therapy that is both safe and beneficial. You may choose to try safer conservative therapies before resorting to corticosteroids, or you may be on corticosteroids and try to see if you can have success with safer conservative therapies and gradually reduce your use of these potentially harmful corticosteroids. Either way, I hope this handout had helped you to make these important decisions.

One more note: many patients feel that the steroid asthma inhalers and medications must be safe because of the widespread use. Clembuterol, an asthma medication similar to albuterol, is used by professional athletes and bodybuilders to promote muscle growth. This steroid inhaler has the same strong effects that other steroids have.

Information Resources

1. A January 13 article in the New York Times reveals that the FDA is finally announcing a sharp restriction on the use of the most popular pain medications due to the enormous amount of death and liver damage resulting from acetaminophen overdosage from numerous sources, including most prescription pain medications, and most over-the-counter nonprescription pain medications since the dangers of NSAIDS have become more widely known. The FDA announcement:http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm239894.htm
2. A 2011 FDA press release outlines the problems seen with acetaminophen poisoning, and new requirements instituted to start decreasing the large problem of acetaminophen liver damage and death: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm239894.htm
3. The array of signs and symptoms resulting from liver toxicity is explained succinctly on medical websites like this: http://www.wellness.com/reference/conditions/liver-toxicity/symptoms-and-causes
4. A simple explanation of liver toxicity and the effect on the P450 catabolic pathway especially is explained on this website: http://www.articledashboard.com/Article/Liver-Toxicity-101---the-P450-Pathway/961346
5. Long-term use of NSAIDS is known to increase GI bleeding and stomach ulcers, but this study shows that mucosal lesions in the colon, and ulcerative colitis may be caused by long-term use of these pain relievers: http://www.ncbi.nlm.nih.gov/pubmed/19817771
6. Long-term use of NSAIDS is also shown to injure the small intestine, and COX-2 inhibitors, created to decrease such GI injury, is proven to be similar in damaging the small intestine, suggesting that the cyclooxygenase 2 (COX2) enzyme is important in maintaining small intestinal health: http:/www.ncbi.nlm.nih.gov/pubmed/17625980
7. Long-term use of NSAIDS and other anti-inflammatory drugs is proven to result in many serious potential health problems. Here, the Institute of Cardiology in Chieti, Italy, studied the effects and reports that there is a high association with atrial fibrillation, a risk factor for heart attack, and NSAID use. We see from this study summary that standard medicine is loath to blame medication for any health problem, though, and speculates that this is due to inflammation causing atrial fibrillation, rather than inflammatory dysregulation from long-term NSAID use causing atrial fib: http://www.ncbi.nlm.nih.gov/pubmed/20837831
8. A research article in the September 2009 issue of the medical publication NeuroImage outlines the mechanisms by which simple acupuncture stimulation exerts an objective mind-body therapeutic response of significance in pain relief, affecting key areas of the brain responsible for pain modulation, and noted the dramatic difference between the measurable effects of so-called sham acupuncture stimulation (stimulation of the trigger points cutaneously) and real acupuncture stimulation with a deeper triggerpoint needling. This seminal fMRI and PET scan study of the brain effects of acupuncture stimulation was conducted by researchers at the Unversity of Michigan in coordination with Kyunghee University in Korea and the Massachusetts General Hospital Martinos Center for Biomedical Imaging, associated with Harvard. This is just one of the array of effects that simple acupuncture stimulation has in the body to promote healing and pain relief holistically. This study demonstrates how the mu-opioid pain receptors were also modulated to increase sensitivity, thereby theoretically enhancing the effects of standard narcotic pain medications and allowing the physician and patient to reduce dosage: http:/www.ncbi.nlm.nih.gov/pmc/articles/PMC2733781/
9. A 1997 study of chronic pain patients by the Multidisciplinary Pain Center of the Danish National Hospital, in Copenhagen, Denmark, found that an array of health problems occur in a majority of patients with chronic pain, including sleep disorders, anxiety and depression, and that neurogenic pain, for which opioid pain medication has no effect, occurred in 65 percent of the study population. This type of study indicated the need for a multidisciplinary and holistic approach to treat comorbid conditions and improve quality of life, yet standard medicine in the United States rejected Integrative and Complementary Medicine and instead drastically increased prescription of opioid and other pain medications as the total package of care: http://www.sciencedirect.com/science/article/pii/S0304395997001267
10. A 2010 study at the University of Southern Denmark found that the odds of recovery from a chronic pain condition were almost 4 times higher among individuals not using opioid pain medication, and that use of high-dosage opioids was associated with a poor health-related quality of life. Studies such as these indicate the benefits of a comprehensive package of care utilizing acupuncture, physiotherapy, herbal and nutrient medicine, and other health disciplines to treat the underlying problems with chronic pain: http://www.ncbi.nlm.nih.gov/pubmed/20842015
11. The National Birth Defects Prevention Study, an ongoing population study sponsored by the Centers for Disease Control and Prevention (CDC) found in 2009 that use of opioid pain medication taken between 1 month before pregnancy and through the first trimester was associated with a higher incidence of birth defects (American Journal of Obstetrics and Gynecology: 2011;204:x.ex-x.ex.): http://www.ajog.org/article/S0002-9378(10)02524-X/abstract
12. A 2002 study at the University of Wisconsin School of Medicine and Public Health found that chronic use of inhaled corticosteroid, such as asthma med inhalers, had a high association with risk of acquiring obstructive sleep apnea: http://chestjournal.chestpubs.org/content/135/5/1125.abstract
13. Bass and Boney Pharmaceuticals website http://www.rosacea-ltd.com/pregnant-rosaceans.php.3 describes birth defect risks
14. A variety of studies have shown by 2012 that long-term use of opioid pain medication results in hormonal suppression, with both the hypothalamic-pituitary-adrenal axis and the gonadal production of hormones suppressed, including the important hormones that are responsible for tissue repair and maintenance, and regulation of inflammatory processes, such as cortisol, testosterone and estrogen. http://www.medscape.com/viewarticle/549294_5 These hormonal effects may result in male as well as female infertility, lowered libido, and increased aggression.
15. A review of studies of hormonal, or endocrine, effects in humans resulting from chronic opioid medication use was presented in a February, 2010 article published in Endocrine Reviews. Here, researchers at Charles Drew University of Medicine and Science, the University of Western Ontario, the University of Texas at El Paso, and the Western University of Health Sciences in Pomona, California, showed that chronic use of opioid pain medication not only affects the standard sexual steroids, but increases thyroid stimulating hormone levels (TSH), producing a diagnosis of subclinical hypothyroidism: http://edrv.endojournals.org/content/31/1/98.full
16. The most conservative listing of common side effects of the corticosteroid prednisone is listed here, on About.com, accredited by Health on the Net http://ibdcrohns.about.com/cs/prescriptiondrugs/p/medprednisone.htm
17. The adverse psychological effects of corticosteroids in children and adolescents may be accessed at this website: British Medical Journal: http://adc.bmj.com/cgi/content/full/90/5/500
18. Standard listing of common side effects of corticosteroids is listed at this website: Lymphomation.org: http://www.lymphomation.org/side-effect-prednisone.htm
19. Respiratory Medicine vol.100, issue 8; 1307017 (Aug 06): http://www.resmedjournal.com/article/PIISO9546110500510X/abstract
20. An example of proof of pain relief from acupuncture and electroacupuncture is presented here, published in 2006 in the Oxford Journal, Rheumatology. The researchers at Peninsula Medical School and the Universities of Exeter and Plymouth in England found that a review of all published studies showed that pain control with acupuncture and electroacupuncture was proven in randomized sham-controlled human trials for treatment of peripheral joint osteoarthritic pain: http://www.ncbi.nlm.nih.gov/pubmed/16936326
21. The neural physiological mechanisms of pain relief, or analgesia, from acupuncture and electroacupuncture are well studied, and reviewed in this article in Progressive Neurobiology: http://www.ncbi.nlm.nih.gov/pubmed/18582529

“long-term use of high-dose inhaled corticosteroid therapy has potential to cause systemic side effects – impaired growth in children, decreased bone mineral density, skin thinning and bruising, and cataracts. Hypothalamic-pituitiary-adrenal-axis suppression, measured by serum or urine cortisol decrease correlates with the occurrence of systemic side effects of high-dose inhaled corticosteroids.”

The information on this website is not intended to be used as a specific medical advice or cure. Please consult with the practitioner or an appropriate physician, such as a licensed acupuncturist, naturopath, or medical doctor, to discuss the proper application of the information contained on this website.