Potential Safety Risks of Pain Medication for Back and Neck Pain

While pain medications offer relief, it's crucial to acknowledge potential safety risks when managing back and neck pain. The side effects and adverse events of pain medications depend on the specific process through which the medication acts on the body. 

Common Side Effects of Pain Medications for Back and Neck Pain

Most pain medications with systemic (whole-body) effects are associated with mild side effects, including ¹ Neurontin. Package Insert. Parke-Davis Div of Pfizer Inc; 2022 ^{- 7} Prednisone. Package Insert. Amneal Pharmaceuticals NY LLC; 2021 :

• Nausea
• Gastrointestinal upset
• Headache
• Dizziness

In rare cases, pain medications may cause severe allergic reactions in individuals with hypersensitivity. ¹ Neurontin. Package Insert. Parke-Davis Div of Pfizer Inc; 2022 ^{, 5} Meloxicam. Package Insert. Lupin Pharmaceuticals, Inc; 2022

Medications that act primarily on the central nervous system (eg, opioids, muscle relaxers, anticonvulsants, and antidepressants) also cause mild to moderate sedation. ¹ Neurontin. Package Insert. Parke-Davis Div of Pfizer Inc; 2022 ^{- 4} Amitriptyline. Package Insert. Advanced Rx Pharmacy of Tennessee, LLC; 2023

Common side effects of topical pain medications

Topical pain medications are associated with little-to-no systemic side effects, but skin irritation and other cutaneous effects are possible, such as rash and itching. ⁸ Voltaren Arthritis Pain. Package Insert. GlaxoSmithKline Consumer Healthcare Holdings (US) LLC; 2023

Handwashing after applying topical medications, especially capsaicin, is important to avoid accidentally spreading the medication to unintended and/or highly sensitive areas, such as the eyes.

Serious Risks of Pain Medications for Back and Neck Pain

The most significant adverse events of pain medications involve organ injury due to the way these drugs are processed and eliminated. Organ issues typically include liver damage (elevated liver enzymes and cirrhosis) and kidney injury (acute kidney injury and chronic kidney disease). ⁹ Vaja R, Rana M. Drugs and the liver. Anaesthesia and Intensive Care Medicine. 2020;21(10):517-523. doi:10.1016/j.mpaic.2020.07.001 ^{, 10} Patel JB, Sapra A. Nephrotoxic Medications. [Updated 2023 May 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553144/

Additional risks of specific pain medications include:

• Pain medications that act on the central nervous system (CNS) may cause CNS depression (profound sedation, cognitive impairment, or respiratory depression). ¹ Neurontin. Package Insert. Parke-Davis Div of Pfizer Inc; 2022 ^{- 4} Amitriptyline. Package Insert. Advanced Rx Pharmacy of Tennessee, LLC; 2023    
• Non-steroidal anti-inflammatory drugs (NSAIDs) are associated with gastrointestinal ulcers and bleeding, and the risk is increased with higher doses and long-term use. ⁵ Meloxicam. Package Insert. Lupin Pharmaceuticals, Inc; 2022
• Systemic corticosteroids may lead to significant immunosuppression when used for long periods, which increases the risk for serious bacterial, viral, and fungal infections. ⁷ Prednisone. Package Insert. Amneal Pharmaceuticals NY LLC; 2021
• Epidural injections and intrathecal injections are associated with risks for serious neurologic complications (eg, stroke or spinal cord injury) and infection due to the potential risk of improper administration. ¹¹ Cohen SP, Greuber E, Vought K, Lissin D. Safety of Epidural Steroid Injections for Lumbosacral Radicular Pain: Unmet Medical Need. Clin J Pain. 2021;37(9):707-717. doi:10.1097/AJP.0000000000000963

This is not a comprehensive list of potential adverse events of pain medications. Patients are encouraged to talk to a medical professional if they have concerns about the risks of a specific drug.

Potential Risks of Opioid Addiction

It has been well-established that opioids are associated with significant risks of abuse, misuse, and addiction due to their central nervous system depressant effects and rapid development of tolerance (the need for higher doses over time to have the original effect). ² Oxycodone. Package Insert. ANI Pharmaceuticals, Inc; 2021 ^{, 12} Tramadol. Package Insert. ACI Healthcare USA, Inc; 2022

The risk of opioid addiction varies from person to person, and it is important to note that an individual does not have to abuse or misuse the medication to become addicted. ² Oxycodone. Package Insert. ANI Pharmaceuticals, Inc; 2021 ^{, 12} Tramadol. Package Insert. ACI Healthcare USA, Inc; 2022

Tolerance to opioids occurs even when the drug is used as directed, and the risk of addiction increases when opioids are used for long periods. ² Oxycodone. Package Insert. ANI Pharmaceuticals, Inc; 2021 ^{, 12} Tramadol. Package Insert. ACI Healthcare USA, Inc; 2022

See Opioid Medication Potential Risks and Complications

Using Pain Medications in Older Adults

The use of many pain medications, including some OTC medications, in older adults is associated with increased risks of side effects and adverse events due to age-related factors ¹³ 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372 :

• The normal function of organs (eg, kidneys, liver, and lungs) naturally declines with age, and older adults are more susceptible to the damaging or suppressive effects of certain pain medications on these organs.
• The ability of the body to process and eliminate medications diminishes with age, leading to exaggerated side effects from medications, especially cognitive side effects, and elevating the risk of other complications and injuries.
• Older adults are more likely to have underlying medical conditions and take multiple medications that can impact the safe use of pain medications.

Pain medications such as opioids, muscle relaxers, and systemic corticosteroids are generally considered unsafe for older adults due to these age-related risks. ¹³ 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372

Using Pain Medications in Pregnancy and Lactation

Some pain medications (eg, NSAIDs and opioids) have been studied extensively, and specific guidance for use during pregnancy or lactation is available. However, other medications have limited safety information, and it is advisable to consult with a doctor before using pain medication in this population.

Use of NSAIDs during pregnancy 

NSAIDs are associated with severe risks to the developing fetus (such as kidney damage, low amniotic fluid, and heart abnormalities) when used at certain stages of pregnancy. ⁵ Meloxicam. Package Insert. Lupin Pharmaceuticals, Inc; 2022 ^{, 14} Celecoxib. Package Insert. Actavis Pharma, Inc; 2022

Generally, NSAIDs are safe to use during the first 20 weeks of pregnancy (first trimester), but they should be avoided during the second and third trimesters. ⁵ Meloxicam. Package Insert. Lupin Pharmaceuticals, Inc; 2022 ^{, 14} Celecoxib. Package Insert. Actavis Pharma, Inc; 2022

Use of opioids during pregnancy 

The use of high-dose opioids, or long-term use of opioids at any dose, has been associated with neonatal opioid withdrawal syndrome or severe respiratory depression in newborns. ² Oxycodone. Package Insert. ANI Pharmaceuticals, Inc; 2021 ^{, 12} Tramadol. Package Insert. ACI Healthcare USA, Inc; 2022  In cases where opioids are used during pregnancy, it is strongly advisable to ensure the proper treatment is available at the time of birth to manage potential withdrawal symptoms quickly.

Use of opioids in women who are breastfeeding

Some opioids can pass into breast milk and present a significant risk of sedation and respiratory depression in breastfed infants. Additionally, infants exposed to opioids through breast milk may experience withdrawal symptoms when the mother stops taking the medication. ² Oxycodone. Package Insert. ANI Pharmaceuticals, Inc; 2021 ^{, 12} Tramadol. Package Insert. ACI Healthcare USA, Inc; 2022

Safe Use of Pain Medications for Back and Neck Pain

While all side effects and risks are not preventable, the safe handling of pain medications reduces the chances of accidental overdose and related complications.

Following dose instructions

The potential side effects and risks of pain medications are primarily dose-dependent, and taking doses higher than prescribed or recommended significantly increases the risk of complications. ¹ Neurontin. Package Insert. Parke-Davis Div of Pfizer Inc; 2022 ^{, 2} Oxycodone. Package Insert. ANI Pharmaceuticals, Inc; 2021 ^{, 5} Meloxicam. Package Insert. Lupin Pharmaceuticals, Inc; 2022 ^{, 6} Tylenol 8HR. Package Insert. Johnson & Johnson Consumer Inc; 2023

Following dose instructions is equally important for OTC pain medications (eg, NSAIDs and acetaminophen) which have daily dose limits due to the potential for severe liver or kidney damage at higher doses. ⁵ Meloxicam. Package Insert. Lupin Pharmaceuticals, Inc; 2022 ^{, 6} Tylenol 8HR. Package Insert. Johnson & Johnson Consumer Inc; 2023

Avoiding manipulation (crushing, splitting, or cutting) of medication

Some pain medications are specially formulated to provide long-lasting effects by releasing small amounts of the drug over time (eg, delayed-release pills, extended-release pills, and transdermal patches). If these medications are crushed, cut, or split, it can cause too much of the drug to be released at once and increase the risk of severe side effects or adverse events. ¹⁵ Fentanyl Transdermal. Package Insert. SpecGx LLC; 2021 ^{, 16} Oxycontin. Package Insert. Purdue Pharma LP; 2021

Limiting the use of alcohol 

Concomitant use of alcohol with many pain medications can increase the risk of sedating side effects. This is particularly dangerous for people taking opioids and muscle relaxers. ² Oxycodone. Package Insert. ANI Pharmaceuticals, Inc; 2021 ^{, 17} Soma. Package Insert. Meda Pharmaceuticals Inc; 2023

Alcohol use also heightens the risk of liver damage when combined with certain drugs, including acetaminophen and NSAIDs. ⁵ Meloxicam. Package Insert. Lupin Pharmaceuticals, Inc; 2022 ^{, 6} Tylenol 8HR. Package Insert. Johnson & Johnson Consumer Inc; 2023

Additional factors influence the effectiveness and safe use of the drugs used in the treatment of back pain and neck pain, and it is important to discuss these and other concerns with a doctor.

Alternative Therapies for Treating Back and Neck Pain

While medications are practical tools for treating back and neck pain, alternative strategies are effective for managing chronic pain and preventing additional injury.

Correcting vitamin and mineral deficiencies may help back and neck pain

Several vitamins and minerals contribute to the overall health of bones, nerves, muscles, and other tissues in the body, and correcting deficiencies of the following vitamins and minerals may help improve back and neck pain:

• Vitamin B12 ¹⁸ Clements M, Heffernan M, Ward M, et al. A 2-Year Randomized Controlled Trial With Low-Dose B-Vitamin Supplementation Shows Benefits on Bone Mineral Density in Adults With Lower B12 Status. J Bone Miner Res. 2022;37(12):2443-2455. doi:10.1002/jbmr.4709
• Vitamin C ¹⁹ Brzezińska O, Łukasik Z, Makowska J, Walczak K. Role of Vitamin C in Osteoporosis Development and Treatment-A Literature Review. Nutrients. 2020;12(8):2394. Published 2020 Aug 10. doi:10.3390/nu12082394 ^{, 20} Hung KC, Chiang MH, Wu SC, et al. A meta-analysis of randomized clinical trials on the impact of oral vitamin C supplementation on first-year outcomes in orthopedic patients. Sci Rep. 2021;11(1):9225. Published 2021 Apr 29. doi:10.1038/s41598-021-88864-7
• Vitamin D ²¹ Khazai N, Judd SE, Tangpricha V. Calcium and vitamin D: skeletal and extraskeletal health. Curr Rheumatol Rep. 2008;10(2):110-117. doi:10.1007/s11926-008-0020-y
• Vitamin K ²² Tsugawa N, Shiraki M. Vitamin K Nutrition and Bone Health. Nutrients. 2020;12(7):1909. Published 2020 Jun 27. doi:10.3390/nu12071909
• Calcium ²³ Reid IR, Bristow SM. Calcium and Bone. Handb Exp Pharmacol. 2020;262:259-280. doi:10.1007/164_2019_324
• Iron ²⁴ Yang J, Li Q, Feng Y, Zeng Y. Iron Deficiency and Iron Deficiency Anemia: Potential Risk Factors in Bone Loss. Int J Mol Sci. 2023;24(8):6891. Published 2023 Apr 7. doi:10.3390/ijms24086891
• Magnesium ²⁵ Shin HJ, Na HS, Do SH. Magnesium and Pain. Nutrients. 2020;12(8):2184. Published 2020 Jul 23. doi:10.3390/nu12082184
• Zinc ²⁶ Amin N, Clark CCT, Taghizadeh M, Djafarnejad S. Zinc supplements and bone health: The role of the RANKL-RANK axis as a therapeutic target. J Trace Elem Med Biol. 2020;57:126417. doi:10.1016/j.jtemb.2019.126417

Before taking vitamin or mineral supplements, consultation with a doctor and laboratory tests to identify the need for supplementation is advisable.

See Diet and Nutrition for a Healthy Back

Natural supplements for back and neck pain

Natural supplements with anti-inflammatory, healing, and pain-relieving properties may provide modest relief from back and neck pain over time, including ²⁷ Zeng L, Yang T, Yang K, et al. Efficacy and Safety of Curcumin and Curcuma longa Extract in the Treatment of Arthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trial. Front Immunol. 2022;13:891822. Published 2022 Jul 22. doi:10.3389/fimmu.2022.891822 ^{, 28} Senftleber NK, Nielsen SM, Andersen JR, et al. Marine Oil Supplements for Arthritis Pain: A Systematic Review and Meta-Analysis of Randomized Trials. Nutrients. 2017;9(1):42. Published 2017 Jan 6. doi:10.3390/nu9010042 ^{, 29} Rondanelli M, Fossari F, Vecchio V, et al. Clinical trials on pain lowering effect of ginger: A narrative review. Phytother Res. 2020;34(11):2843-2856. doi:10.1002/ptr.6730 :

• Turmeric
• Ginger
• Fish oil

Interactions between supplements and medications have the potential to cause serious side effects or reduced effectiveness, and it is important to speak with a qualified healthcare provider before use.

Considering non-drug therapies for back and neck pain

Alternative treatments that may help to alleviate back and neck pain include ³⁰ Nahin RL, Boineau R, Khalsa PS, Stussman BJ, Weber WJ. Evidence-Based Evaluation of Complementary Health Approaches for Pain Management in the United States. Mayo Clin Proc. 2016;91(9):1292-1306. doi:10.1016/j.mayocp.2016.06.007 ^{, 31} Hamblin MR. Mechanisms and applications of the anti-inflammatory effects of photobiomodulation. AIMS Biophys. 2017;4(3):337-361. doi:10.3934/biophy.2017.3.337 :

• Physical therapy
• Massage therapy
• Heat and cold therapy
• Yoga and stretching
• Acupuncture
• Cognitive behavioral therapy (CBT)
• Red light therapy (photobiomodulation)
• Transcutaneous electrical nerve stimulation (TENS)

Combining alternative therapies with pain medication optimizes pain management and function. ²⁷ Zeng L, Yang T, Yang K, et al. Efficacy and Safety of Curcumin and Curcuma longa Extract in the Treatment of Arthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trial. Front Immunol. 2022;13:891822. Published 2022 Jul 22. doi:10.3389/fimmu.2022.891822

Preventing additional injury to avoid worsening back and neck pain

Lifestyle modifications that may help to prevent further damage or worsening of back and neck pain include:

• Engage in regular low-impact exercise and avoid prolonged periods of inactivity.
• Minimize high-impact and repetitive activities that strain back and neck muscles.
• Maintain proper posture and make ergonomic adjustments.
• Use footwear and shoe inserts that provide proper support.
• Invest in a mattress and pillow that adequately supports the back and neck.

Additionally, maintaining a healthy weight, consuming a well-balanced diet, and ensuring adequate hydration all contribute to promoting the body's natural processes of healing and maintenance.