COX-2 Inhibitors vs. Opioids for Back or Neck Pain

From anti-inflammatories to opioids and antidepressants and more, many types of medications are prescribed for back and neck pain. Most offer at least some pain management benefits. However, they may also have unpleasant, even dangerous side effects.

This article compares two such medications — COX-2 inhibitors and opioids.

Pill bottle
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COX-2 Inhibitors: Celebrex, Vioxx, and Bextra

COX-2 inhibitors are a type of non-steroidal anti-inflammatory (NSAID) medication used for acute pain. They differ from drugs like aspirin, acetaminophen (Tylenol), naproxen sodium (Aleve), or ibuprofen (Motrin, Advil) in that their action is specifically targeted to the COX-2 enzyme.

Scientists and doctors know that pain is caused by substances known as prostaglandins. Prostaglandins, in turn, are produced in the body by two related enzymes (each with slightly different effects): COX-1 and COX-2. Prostaglandins specifically responsible for pain, swelling, and inflammation are produced by both COX-1 and COX-2 enzymes.

The main difference between traditional non-steroidal anti-inflammatory pain medication (i.e., the various forms of NSAIDs) and COX-2 inhibitors is that while NSAIDs inhibit the actions of both COX-1 and COX-2 enzymes, COX-2 inhibitors, as the name implies, suppress only the COX-2s.

The problem is most COX-2 inhibitors have been taken off the market. This is because they were found to increase risk for cardiovascular events (heart attacks and strokes) when used over time. Vioxx (generic name rofecoxib) and Bextra (generic name valdecoxib) were withdrawn from the market in the early 2000s. Vioxx was manufactured by Merck, and Bextra was manufactured by Pfizer.

That leaves Pfizer's other COX-2 inhibitor, Celebrex (celecoxib). As the only drug of the three COX-2 inhibitors remaining in the U.S. market, Celebrex and celecoxib now come with a "black box warning," which is a label designed to stand out enough to alert you to the questionable safety profile of the drug.

Physicians who prescribe Celebrex have been instructed by the FDA to give you a medication guide covering risk and dosage information.

If you're wondering what else you can take besides Celebrex, a 2013 review found that of all the non-selective NSAIDs, naproxen sodium (Aleve) likely poses the least amount of cardiovascular risk to patients. The review authors recommend that whichever NSAID you use, you do so in the lowest dose and for the shortest amount of time possible.

Note that the other types of NSAIDs, which inhibit both COX-1 and COX-2 enzymes, may increase your risk for heart attack or stroke as well. In fact, in 2015, the FDA ordered the wording on all NSAID box labels (including Celebrex) be updated to reflect new research that found heart attacks can occur even weeks after starting this type of drug, and that the longer you use the drug, the higher that risk may become.

Opioids for Back or Neck Pain

Opioids are a class of medications that have the capacity to deliver very strong pain relief. Opioids are often used for severe back pain, but doctors sometimes prescribe them as first-line treatments for mild to moderate pain.

The problem is, this category of pain relievers is narcotic, which means they come with the potential for addiction. Some patients build up a tolerance, which can lead to physical dependence and even eventually full-blown addiction.

Some opioid medication are pure narcotics, while others are mixed with less addictive pain relievers such as acetaminophen. Opioids are formulated as short-acting and long-acting.

Even though the use of opioids for neck and back pain is widespread, evidence does not necessarily support this practice. A 2015 review in the British Medical Journal reports that opioids are now the most commonly prescribed drugs in the United States.

That said, the review authors note, opioids don't seem to help people get back to work any faster than other types of back pain treatment, nor do they improve outcomes of primary care for acute back pain.

If your back pain is chronic, opioids may not do anything for you at all. The review authors found little evidence that they work for this purpose.

Along with the risk for addiction, opioids come with other side effects, including constipation, sexual dysfunction, and depression, to name only a few.

The pharmaceutical industry has been known to downplay the risks of prescription opioids. One brand of opioid, OxyContin, or oxycodone, was touted as a "safe" narcotic by company representatives in a very successful marketing campaign. But the top executives of Purdue Pharma, makers of OxyContin, later admitted in court that those claims were misleading.

Think Before You Take

When you consider or are prescribed pain medication, speak with your primary physician and pharmacist regarding the possible side effects that could arise from taking it. Do not make assumptions or take advice from an unlicensed individual regarding your health care. Build a relationship with your physician and pharmacist to make sure you stay on top of avoidable risks and addiction from pain medication.

Remember, quite often moving your body can help with back pain as well as help you regain lost function and improve your quality of life. Visiting a physical therapist or starting a gentle yoga and exercise program under your doctor's supervision may be all you need to reclaim your quality of life.

Celebrex and other COX-2 Inhibitors

COX-2 inhibitors like Celebrex, Vioxx, and Bextra are a type of NSAID or non-steroidal anti-inflammatory drug. They were developed in the 1990s in response to the side effects of NSAIDs.

Because they are in the same family of medication, all COX-2 inhibitors behave in pretty much the same way. Therefore, patients who replace Vioxx or Bextra with Celebrex may still be at risk for heart attack. Although they are not COX-2 inhibitors, other NSAIDs that pose potential cardiovascular risks are Motrin, Naprosyn, Voltaren, and Mobic.

Opioids

Opioids are used for moderate to severe pain. In addition to chronic back pain, opioids are also administered in cases of cancer pain, nerve pain, and other conditions.

Opioids are very strong pain relievers. Morphine is the best-known example of an opioid, although there are actually several types that range from mild-acting to very strong. Examples include oxycodone (OxyContin, Percocet, others), codeine (Tylenol 3), hydromorphone (Dilaudid), and hydrocodone/acetaminophen (Vicodin).

Opioids have several side effects, including the possibility of:

  • Respiratory depression
  • Constipation
  • Risk of dependency and addiction

The most obvious disadvantage of opioids as pain medication is the potential for addiction and dependency. Research indicates that OxyContin, in particular, is a "gateway" to addiction to other hard drugs. Sometimes, patients may be denied the medication because their motivations are misunderstood, and they may be seen as potential morphine (or other opioids) addicts.

Outcome

When opioid medication is properly administered for pain, the benefits may outweigh the risk depending on the case and the individual patient. And many researchers, governing bodies in medicine, and doctors feel that opioids are worth considering for the treatment of chronic pain. But as with any health care choice, work with your doctor and other health care professionals to find the best option for you.

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Article Sources
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  7. FDA Drug Safety Communication: FDA strengthens warning that non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) can cause heart attacks or strokes. US Food & Drug Administration. February 2018.

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  9. Compton WM, Jones CM, Baldwin GT. Relationship between Nonmedical Prescription-Opioid Use and Heroin Use. N Engl J Med. 2016;374(2):154-63.  doi:10.1056/NEJMra1508490

Additional Reading
  • Deyo, R., et. al. Opioids for low back pain. Clinical Review. State of the Art Review. Jan 2015.

  • Nissen, S., et. al., Cardiovascular Safety of Celecoxib. N Engl J Med. Nov 2016.

  • Pawlosky, N. Cardiovascular risk Are all NSAIDs alike? Can Pharm J. March 2013.