The use of prednisone in chronic neck and low back pain is extremely common but frequently unappreciated especially in this modern day of high priced medicine pushed by Big Pharma.
A Medical text book from 1971 reads “frequently a dramatic reduction of pain is seen with oral use of prednisone.”
Whether administered IV or in a Medrol Dosepak, it is the experience of those of us in the More Corsets-Less Opioids project that a four or five-day course, repeated two or three times over the first two to four weeks, is the best way to use prednisone. Lower doses of prednisone are not as effective as the high doses. If the dose needs repeated, it is better to repeat four days than seven days.
A typical dose for an average size male, 175 pounds or more, would be for severe sciatica: 50 mg for one day, 40 mg for two days and 30 mg for one day repeated two to three times. Average size women and smaller men can frequently get a very nice response to 40 mg of prednisone for two mornings and 30 mg of prednisone for two mornings.
Patients over 65 years of age can reduce their dose 10mg/day.
The advantage of a four day course of prednisone is that significant side effects rarely happen and if we are repeating doses, secondary side effects rarely happen.
The most common side effects in short-term usage are anxiety or sleeplessness that occur in about one out of twenty people. Indigestion or GI symptoms are actually extremely rare in a four day course of oral prednisone repeated three times in a month. If there is any worry about GI symptoms, a Prilosec-type drug may be prescribed as well. Although extra caution is needed with Diabetics, short courses of oral prednione is very effective with only temporary rises in blood glucose.
The use nonsteroidal anti-inflammatories in sciatic and degenerative disc disease is required in many cases. Using them q.h.s. (at bedtime) simultaneously with prednisone allows the prednisone to be the main anti-inflammatory in the first few weeks of medication and of treatment with the NSAID use primary q.h.s. only. A q.h.s. dose only allows the patient to control his pain with the corset, a walking program and sitting precautions rather than just relying on medication two to three times a day. With corset use and oral prednisone, patients with sciatica, lumbosacral disc injury and severe pain are frequently, within the first few weeks, on a q.h.s. NSAID dose only, as long as they are following the other protocols.
Side effects of NSAIDs are well-known and it is recommended a once a day dose q.h.s. only be given for several reasons:
Fewer side effects
Reduces pain with evening sleeping
A nighttime dose does not mask chronic sitting pain or chronic pain with ambulation which may prolong the back injury.
Introduction - Pain Medications
Primary Care Physicians as well as Pain Management Specialists can learn something from Veterinarians who take care of race horses. The first group of athletes to be tested for performance enhancing drugs were race horses. Drug testing became necessary to prevent trainers from using pain killers while the horse was injured. Horses running while their pain is masked can break their leg and have to be put down.
Using round the clock painkillers prevents the patient from knowing which activity - including physical therapy - might actually be causing further injury. Even walking should be done without daytime NSAIDS as soon as possible. Most NSAIDS are analgesics as well. NSAIDs at night while resting would be the best time to actually reduce inflammation in the discs, joints and nerves.
Nighttime dosing with muscle relaxants is frequently required in severe lumbosacral disk injury - at least sometimes for the first few weeks.
Cyclobenzaprine 10 or 15 mg q.h.s. dose is an inexpensive and excellent muscle relaxant and sedative. These can be given primarily q.h.s. only as it effects wakefulness. Sleeping medications such as temazepam 15 mg q.h.s. are complementary to NSAIDs as well at nighttime for sleeplessness. Other muscle relaxants such as Soma are given in short doses and not prescribed for more than one month.
Gabapentin is an anti-epileptic drug that has been promoted for nerve pain relief. A few studies have shown that it does not have any significance except for somnolence on a regular basis. It is our feeling that many people, when given the oral prednisone treatment, find that gabapentin is unnecessary and even high doses can be titrated off simply down to a q.h.s. only or a p.r.n. dose as needed.
With the epidemic of prescription drug deaths in this country, it is strongly recommended that any opioids be given for no more than 14 days and primarily q.h.s. (at bedtime) only. As is well-known, opioids do not actually work on the back, but only work on the brain and can be lethal: in the USA, 100 deaths per day are caused by overdose of prescription drugs.
It should be a goal of primary care physicians to get people off of opioids as soon as possible and rarely should they be taken more than q.h.s. except in the first few days of a severe lumbosacral disk injury.
Opioids work on the central nervous system as opposed to the lumbar spine. Drugs like oral prednisone, which are extremely inexpensive, work in the lumbosacral disk and the nerves and are a much better pain reliever than opioids in both the short and long terms.