In today’s post, we will delve into the UK national guidelines (i.e., NICE) for sciatica treatments and shed light on the recommended approaches. We will begin by exploring medication options and provide insights into important considerations when seeking treatment in Singapore.
The recommendations and content of this post is specific to sciatica. If you have multiple complaints (i.e., back pain plus sciatica), your treatment plan may, for good reason, look different from the recommends discussed below.
Gabapentinoids, other antiepileptics, oral corticosteroids or benzodiazepines
Do not offer gabapentinoids, other antiepileptics, oral corticosteroids or benzodiazepines for managing sciatica as there is no overall evidence of benefit and there is evidence of harm.
This recommendation was added in in 2020. Likely because more recent clinical trials showed that gabapentinoids (e.g., Lyrica) are not better than placebo for sciatica or radicular pain.
A study published earlier this year found that clinical trials conducted between 2001 and 2005 reported pregabalin to be more efficacious than trials conducted in 2016 to 2020. This is where science becomes interesting because how can the same drug give different results over different period?
What even is pregabalin?
Pregabalin is belongs to a group of drugs known also as anticonvulsants. While often prescribed to treat neurogenic pain from conditions such as sciatica, diabetes, and even shingles.
It works by specifically binding to calcium channels found in the brain (e.g., neocortex, hippocampus, amygdala) and spinal cord. In doing so, pregabalin modulates the release of certain neurotransmitters (e.g., glutamate, noradrenaline, and substance P) which are involved in pain signalling. The end result is an reduction of excessive electrical activity and hyperexcitability of nerve cells that contribute to neuropathic pain.
Is pregabalin prescribed in Singapore?
Even though current research does not support the use of pregabalin, every client in Singapore whom we have worked with with MRI-confirmed disc herniation + radicular pain has been prescribed with Lyrica. In fact, one of our clients’ parent is on Lyrica for sciatica years now!
Pregabalin is still frequently prescribed for nerve pain. If you have been prescribed with pregabalin by your healthcare provider and do not find it to be effective, do bring it up with them on your next visit and ask for alternative pain management options.
What about benzodiazepines?
We also know of benzodiazepines (e.g., diazepam, lorazepam) being prescribed for acute sciatica. This is usually to take some of the anxiety off and also to promote sleep. Most of the prescription we have seen are either in-patient (i.e., warded in hospital) or only for a couple of days upon discharge. In our opinion, this is reasonable.
Because of the side effects, which can include memory impairment and confusion, long-term or regular benzodiazepines is no longer preferred even for most mental health conditions.
Do not offer opioids for managing chronic sciatica
Opioids do have a bad rep because of the side effects, specifically how addictive it is, that is associated with it. It is estimated that up to 1.2 million people in US and Canada alone would die from an opioid overdose! Yes, it is a big deal.
The opioid crisis has become such a problem that the Sackler family, owners of opioid manufacturer Purdue, has agreed to pay $6 billion to settle the opioid lawsuits. Over 20 institutions such as Oxford University and Louvre Museum have dropped the Sackler’s name to distance themselves from the company.
The harm opioids brings simply outweighs the benefit. You can imagine why opioids have fallen out of favour, especially in the treatment of chronic conditions.
Having said that, opioids do have a role to play in acute pain management. It is very easy to get a prescription for Tramadol, a type of opioid, if you see a private specialist/surgeon. In public health, it is harder to get a prescription for it but you can definitely still get one. They are often prescribed to help with acute pain, and patients are often discouraged from using them.
Stronger opioids such as OxyContin and Vicodin are definitely harder to come by for management of musculoskeletal pain.
Explain risk of continuing with opioids, gabapentinoids or benzodiazepines
If a person is already taking opioids, gabapentinoids or benzodiazepines for sciatica, explain the risks of continuing these medicines.
This recommendation is specifically directed at healthcare providers. I guess very often it’s easy to prescribe what already works for the patient, and maintain the status quo. However, NICE guideline is explicitly asking doctors to take a proactive approach at educating their patients.
The side effects of opioids are many, it includes:
- Sedation and drowsiness
- Nausea and vomiting
- Respiratory depression
- Itching and rash
- Hormonal effects
- Dependency and addiction
- Overdose and respiratory failure
The side effects of gabapentinoids are less severe but still significant. It includes drowsiness, fatigue, weight gain, cognitive and coordination difficulties, as well as depression and anxiety.
As for benzodiazepines, most of the side effects seem to revolve around interruption of brain processes. Specifically, memory and cognitive issues, motor coordination difficulties, slurred speech, decreased alertness. Benzodiazepines are also highly addictive so patients are at risk of dependency with long-term use.
Discuss problems associated with withdrawal
As part of shared decision making about whether to stop opioids, gabapentinoids or benzodiazepines for sciatica, discuss the problems associated with withdrawal with the person.
This is an exceptionally huge topic to unpack and we will leave this for another post. If you are experiencing withdrawal symptoms from your medications, please to speak to a your family doctor for advice. You can also follow the links to read more about NICE recommendations to managing withdrawals.
What about NSAIDs aka non-steroidal anti-inflammatory drugs?
NSAID is a fairly big topic to uncover and can probably work as a standalone post. Most of our previous content regarding anti-inflammatories relate to back pain. Do note that the below recommendations are specific to sciatica alone.
Be aware of the risk of harms and limited evidence of benefit from the use of non-steroidal anti-inflammatory drugs (NSAIDs) in sciatica.
You can purchase NSAIDs at your local pharmacy without a prescription. They are available in both oral and topical formats. For oral medication, you can get ibuprofen and naproxen over-the-counter. Examples of NSAIDs that are prescription only are diclofenac, ketoprofen, etc. For topical applications, ketoprofen plasters (KefenTech) and fastum gel are available without requiring a prescription.
You can say that it is NSAID is not recommended for sciatica because of the limited benefits. From our experience, most patients with sciatic pain do not experience any relief with NSAID use.
For acute cases with fairly high pain scores, arcoxia or etoricoxib, may be prescribed for short-term use. This is often more for cases where there is a musculoskeletal complaint such as back pain rather than sciatica alone.
NSAIDs are considered relatively safe when taken within prescribed amounts. The most common side effect is gastrointestinal issues such as stomach pain, heartburn, indigestion, nausea, vomiting, etc. Prolonged use, especially with stronger NSAIDs, comes with risk of stomach ulcers or bleeding.
If prescribing NSAIDs for sciatica:
- Take into account potential differences in gastrointestinal, liver and cardio-renal toxicity, and the person’s risk factors, including age
- Think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment
- Use the lowest effective dose for the shortest possible period of time.
The above are considerations your doctor should have when prescribing NSAIDs. If you are prescribed NSAIDs but you are uncomfortable with the treatment plan, you can bring up the above concerns for their feedback.
Sciatica Treatment in Singapore
Sciatic pain can be challenging to live. In fact, the pope had to miss the Vatican’s New Year’s liturgies in 2021 because of sciatica and apologised for being unable to stand for a tribunal. If you are currently struggling to find an effective sciatica treatment, you are not alone!
We have come a long way with modern medicine. However, despite advances in science and technology, pharmacological treatments for sciatic pain remains unpromising. In the upcoming posts, we will discuss conservative pain relief and surgical options for sciatic pain within an evidence-based framework.
Drop us a message via the form below to find out more about how we can help you find freedom from pain. For more evidence-based content, feel free to check out our Facebook group.
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Frustrated by the lack of results-driven and ethical chiropractic clinics in Singapore, Chiropractor Jesse Cai found Square One Active Recovery to deliver meaningful and sustainable pain solutions.
Our goal? To make our own services redundant to you.