What now for pain?

Americans who relied on the drug Vioxx for pain relief do have alternatives, doctors say. Just no perfect ones.

In the wake of the abrupt withdrawal of Vioxx from the marketplace, physicians across the country have been flooded with phone calls from anxious patients worried about possible stroke risk and damage to their hearts -- and what they could use instead.

“We couldn’t handle anything else for hours,” said Dr. Daniel J. Wallace, a rheumatologist at Cedars-Sinai Medical Center in Los Angeles who fielded 200 to 300 calls the day after Merck & Co.’s Sept. 30 announcement that it would stop selling the drug. The company cited new research that showed the drug doubled the incidence of heart attacks and strokes in people who took it for extended periods.

“But our message to patients is ‘Don’t panic,’ ” Wallace said. “There are plenty of other treatment options, and the risk of cardiovascular problems is actually quite small.”

Patients who stop taking Vioxx immediately shouldn’t be in any danger from residual effects, because the drug clears out of the body within a few days.

“There doesn’t seem to be any long-term damage,” said Dr. Antonio Gotto, a cardiologist and dean of the Weill Medical College of Cornell University in New York. That was welcome news for the 1.3 million Americans who were using the blockbuster painkiller.

Some experts said the drug’s removal was a positive development. They say it will force doctors to reevaluate their patients’ treatment, possibly switching them to far less expensive alternatives, such as over-the-counter painkillers.

But that reevaluation may not be easy.

“These drugs have been heavily promoted as wonder drugs for arthritis and pain,” Dr. Joel D. Hyatt, assistant medical director for the Southern California region of Kaiser Permanente, said of Vioxx and two similar drugs, Celebrex and Bextra. “But they are really no more effective than [older drugs] Motrin or Naprosyn.”

The newer drugs, which belong to a class of medications known as Cox-2 inhibitors, target one enzyme that causes inflammation but ignore another that protects the stomach lining. Consequently, the drugs have been considered safer than older drugs for patients who were at heightened risk for gastrointestinal bleeding, such as elderly arthritis sufferers, people taking steroids or blood thinners and patients with a recent history of ulcers or gastric disorders.

Many patients anecdotally reported getting much better pain control with Vioxx than with other drugs, said Dr. Sudhir Diwan, a pain management specialist at New York-Presbyterian Hospital in New York. But in head-to-head studies, the blockbuster drug didn’t provide any more pain relief than older anti-inflammatory drugs such as aspirin, ibuprofen (Motrin, Advil) and naproxen (Naprosyn, Aleve), all of which are sold over the counter.

The absence of a clear choice for pain relief leaves doctors and patients in something of a quandary.

“Everyone reacts differently,” said Dr. W. Hayes Wilson, chief of rheumatology at Piedmont Hospital in Atlanta. “So the best drug will be the one that works for you and doesn’t give you side effects.”

The cheaper, nonprescription pills may seem an obvious choice. After all, they haven’t been linked to heart attacks. But the pills can irritate the lining of the gastrointestinal tract, causing ulcerations and internal bleeding. Side effects from these medications are responsible for at least 10,000 deaths and 100,000 hospitalizations every year in the United States.

Meanwhile, the specter of the Vioxx findings looms over the other Cox-2 inhibitors.

Experts are not sure why Vioxx causes cardiovascular problems, Gotto said. Because Cox-2 inhibitors block a protein responsible for the health of blood vessels, they may promote the formation of blood clots, which would increase the incidence of heart attacks and strokes. A report in last week’s New England Journal of Medicine suggested that Celebrex may share Vioxx’s problems.

Physicians are now being more cautious about the Cox-2 inhibitors, especially in patients with heart disease.

Most people who took Vioxx didn’t need the gastrointestinal protection. Although nearly half of chronic pain patients received prescriptions for Cox-2 inhibitors, only about 5% of them were at greater risk of irritation and bleeding, said Dr. David Campen, medical director of drug information, utilization and technology at Kaiser Permanente in Oakland. The other Cox-2 inhibitors may cause stomach trouble or rashes in people with allergies to sulfonamides, he said.

Pain sufferers who aren’t in high-risk groups might be better off with nonprescription pain drugs, experts say, which cost pennies a day versus about $80 a month for the prescription pills.

Those who are looking for simple pain relief and don’t need something to combat inflammation should consider acetaminophen (Tylenol), said Dr. Eric L. Matteson, a rheumatologist at the Mayo Clinic in Rochester, Minn. It’s just as effective as nonsteroidal drugs, and it doesn’t irritate the stomach.

Others could try a combination of drugs, he said. Antacids (Pepcid, Zantac) or proton pump inhibitors (Nexium, Losec) that are used for ulcers or acid reflux can be taken with nonsteroidal drugs to prevent stomach trouble, he added.

Some people may be able to skip pain medications altogether. Nondrug approaches, such as osteopathic manipulation, can ease pain too. In addition, low-impact exercise, such as swimming and biking, and losing weight, which relieves stress on joints and muscles, are often the best ways to alleviate arthritis symptoms.

Consult your doctor to figure out what’s best given your health conditions, Wilson said.

“Many patients have already tried numerous medications,” he added, “so sitting down face to face to map out a strategy is always the best way.”

One last thing: Patients who have leftover Vioxx shouldn’t throw it away. Merck will reimburse patients for unused pills in the original pharmacy packaging. For more information about the refund, visit the Vioxx website at www.vioxx.com or call (888) 368-4699.

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What to try instead of Vioxx

Although many pain drugs are available, nonsteroidal anti-inflammatory agents are often recommended for conditions such as arthritis because they also reduce inflammation. Here are some of the leading alternatives to Vioxx.

Celecoxib: A Cox-2 inhibitor; brand name Celebrex; available by prescription; may increase risk of stomach bleeding.

Valdecoxib: A Cox-2 inhibitor; brand name Bextra; available by prescription; may increase risk of stomach bleeding.

Ibuprofen: Brand names Motrin and Advil; nonprescription; can irritate the gastrointestinal tract; prolonged use can increase the risk of kidney and liver damage; should be used with caution by people taking blood thinners and those with high blood pressure or poor heart function.

Naproxen sodium: Brand name Aleve; nonprescription; can irritate the gastrointestinal tract and impair kidney function.

Aspirin: Common name for acetylsalicylic acid; can irritate the gastrointestinal tract; should not be with blood thinners such as warfarin.