Nonsteroidal anti-inflammatory drugs (NSAIDs) are readily available for our consumption and they certainly have a place in this world for managing pain and inflammation. You may be more familiar with names such as Ibuprofen, Aspirin, Naproxen, Aleve, Advil, and Diclofenac. Thank goodness they provide an alternative to opioids, since that cat is out of the bag about their addictive properties. Here's a quick story for you...back in 2014ish, I worked at a larger clinic where certain patients ONLY came to physical therapy because their doctors made them a deal. The deal was if they went to PT regularly, then their opioid prescription would be refilled. These patients admitted that to me! They didn't give a hoot about PT. It was awful. Thank goodness that ugly time of opioid prescribing is over. Okay, back to NSAIDs... Since they are so easy to purchase and prescribed regularly, they are probably harmless, right? Not so fast!
Let's review the phases of healing. First, we have the inflammatory phase that lasts roughly 7-10 days. An injury occurs, so then our body increases blood flow to the area (after initially restricting it to minimize blood loss). Cells in that blood release certain chemicals to signal we need white blood cells for taking care of the damaged bits and for "eating" the possible bacteria while at the same time signaling for fibroblasts to build new tissue. The granulation phase is for remodeling and repairing and although it seems like it happens in succession to the inflammatory phase, it's actually occurring at the same time and is in full force by days 5-7 post injury. The maturation phase is when all of the rebuilding is given the finishing touches around 3 weeks post injury and can be ongoing for 12 months.(5) That's right, some tissue repair takes one year to complete! But wait...isn't the inflammatory phase part of our natural healing response and so delaying this phase could delay healing? Ah, so...
Before I tell you about the research, let me emphasize that this isn't an anti-NSAIDs post. NSAIDs are one of the many tools we have for pain control and there is no shame in using them. As mentioned earlier, they get us away from using opioids, which is a blessing in itself. If you choose to use NSAIDs, you might as well be informed. So, here we go.
Prolonged use of NSAIDs and steroids have been shown to delay fracture healing. Research has demonstrated a non-union (basically a gap) within the fracture or a decrease in the callus formation that is usually seen in the early stages of a fracture repair (1, 2, 3). If using them for pain relief after a bone injury, it is recommended to discontinue using them beyond 10 days (1). Prolonged NSAID use has also shown to delay wound healing (5). In another study, patients with moderate to severe knee osteoarthritis (OA) that used NSAIDs for 4 years demonstrated worse cartilage quality and inflammation in their knee joints compared to the control group of people who had knee OA that did not use NSAIDs.
Steroid injections also worsened knee arthritis after a 3-year follow up compared to a control group (4). Chronic NSAID use has been correlated with various issues to organs including the gastrointestinal tract, cardiovascular system, the kidneys, and the liver (6, 7). Yikes!
What can we take away from all of this? Well, like all of these studies suggest, we don't really know how much is too much. There is no tipping point of how many NSAIDs is too many that the scientific community is aware of. However, it would be wise to weigh the risks and benefits in each scenario if you decide to take them. If taking an NSAID means you get through that important meeting, survive the long car ride, or actually get a good night's sleep, then those instances take priority. It is during sleep where we heal the most and we all know how our emotional and pain tolerances plummet with bad sleep. But after 10 days, it is worth exploring other modes of pain management, including exercise, turmeric supplements*, curcumin supplements*, tart cherry juice concentrate, a low-inflammatory diet, visualization, and deep breathing. It is also beneficial to try different modes of therapy that have demonstrated in the research to provide pain relief such as acupuncture, physical therapy, massage therapy, and cognitive behavioral therapy. Basically, if there are movements you can do or postures you can adjust that decrease pain, do them instead! The more active you are in your recovery, the better because you gain a sense of power, confidence, control, knowledge, ownership, and resilience. Besides, acute pain can be a great hint that we need to change the way we are doing something, from drinking more water to changing our pillow to breaking up with that annoying partner that you never liked in the first place, for example.
*A heed of warning with supplements: not all supplements are created equal. To know the quantity and quality that has shown to be effective in the research, check out the book "Taming Pain".
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Check out this article about acetaminophen and liver toxicity: https://www.northwell.edu/news/in-the-news/acetaminophen-overdose-has-become-the-leading-cause-of-liver-failure-in-the-us-data#:~:text=Acetaminophen%20overdose%20is%20the%20leading,of%20complications%20from%20acetaminophen%20toxicity.