By David Seaman, DC, MS, DABCN
More than 50 million Americans suffer with chronic pain, accounting for more than 25 million physician visits per year for low back pain alone.  The outcome is a nation of people who rely on nonsteroidal anti-inflammatory drugs (NSAIDs) for relief.
Unfortunately, this is associated with various side effects that can be life-threatening for some. The second leading cause of peptic ulcers is the use of NSAIDs. Concerning ulcer-induced mortality, one third of NSAID / aspirin deaths are associated with low-dose aspirin use, presumably to prevent cardiovascular disease.  NSAID use is also associated with cardiovascular mortality, particularly in the elderly. Associations exist for both selective COX-2 inhibitors, such as Celebrex, and non-selective NSAIDs, such as ibuprofen and naproxen. 
Diet Is Connected to NSAID Use
It is well-known that dietary omega-6 fatty acids (linoleic and arachidonic acid) become a painful prostaglandin (PGE2) and a cardiovascular-promoting thromboxane (TXA2). [3-4] Also well-known is that we in America consume excessive levels of omega-6-rich foods.  Over time, excess omega-6 fatty acids become incorporated in human tissues, an example being joints. Studies have identified an excess concentration of arachidonic acid in arthritic joints. [6-9] In 1991, it was determined that the histological severity of osteoarthritis was associated with increasing levels of arachidonic acid. 
In short, this means we need to stop eating plates full of “pain” – the best examples of which include fast food, bags of potato chips, and omega-6-oiled packaged foods. It is difficult to modulate pain unless the excessive consumption of “painful” foods is slowed.
Chronic NSAID Use Is No Surprise
Based on the fact that we consume arachidonic acid / PGE2 excessively, it is no surprise that we have become reliant on drugs that inhibit the COX enzyme that converts arachidonic acid into painful PGE2. Consider comments from a recent Cochrane review:  “Non-steroidal anti-inflammatory drugs (NSAIDs) are the most frequently prescribed medications worldwide and are commonly used for treating low-back pain.”
Dietary Changes to Reduce Pain
Making behavioral changes to reduce dietary inflammation is not easy for most people, so the likelihood that a substantial reduction in NSAID intake will occur in the near future is not high. Motivating patients to consider that food choices can influence painful body chemistry is very important – urging people to eat more vegetables, fruit, nuts, omega-3 seeds, and lean animal protein is known to substantially reduce the inflammation chemistry associated with pain. [3-4, 11-14]
An added benefit to making such dietary changes is that fruits and vegetables contain salicylates. Vegetable and fruit intake at a level consumed by vegetarians provides a level of dietary salicylates that appears to be equivalent to 75 mg of aspirin. [15-16]
Basic supplementation should also be considered. No matter what level of dietary change is made, supplementation with magnesium, vitamin D and omega-3 fatty acids seems reasonable, as low levels of each have been linked to the expression of inflammation. [3,17-18] Magnesium deficiency in animal models is known to increase nociceptive activity,  and vitamin D deficiency has been linked to musculoskeletal pain expression in general [20-21] and with low back pain in particular.  These supplements may be beneficial no matter what level of dietary change is initiated.
White Willow Bark
An additional supplement to consider is white willow bark, which may be an effective alternative to NSAID use. Bogduk  provides the following commentary on its efficacy:
“Studies of natural therapies have provided a challenging alternative to conventional drugs for the management of acute low back pain, at least in the context of exacerbation. Controlled trials have shown that willow (Salix) bark extracts are more effective than placebo, and no less effective than a COX-2 inhibitor or NSAID; yet they are considerably less expensive.”
In 2007, the American Pain Society and the American College of Physicians developed a joint clinical practice guideline for the treatment of acute low back pain that was published in the Annals of Internal Medicine.  The level of evidence supporting the use of white willow was fair and the net benefit was moderate, which is the same benefit as acetaminophen, NSAIDs and muscle relaxants.
The dose of salicin that was used to offer analgesic benefits, 240 mg, is found in 1,000 mg of white willow bark extract. Side effects with white willow are less than with NSAIDs and the same as placebo. [25-26] Salicin is converted to salicylic acid after absorption, which is thought to be a reason why there are minimal side effects compared to aspirin and traditional NSAIDs. 
Additionally, 240 mg of salicin produces salicylate concentrations equivalent to those after consumption of 100 mg acetylsalicylate, which is a more cardioprotective rather than an analgesic dose. Other co-active compounds such flavonoids provide the additional the anti-inflammatory and analgesic effects and are not harmful to the gastrointestinal mucosa, in contrast to acetylsalicyclic acid (aspirin). 
Dietary change appears to be a key to creating body chemistry that is anti-inflammatory / analgesic. Supplemental magnesium, vitamin D, and omega-3 fatty acids are important additions. White willow bark extract can be used as a natural analgesic as needed.
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