The painkiller cycle: why Diclofenac isn't fixing your back pain

India is one of the largest consumers of NSAIDs (non-steroidal anti-inflammatory drugs) in the world. Diclofenac, Aceclofenac, Ibuprofen, and their combinations with muscle relaxants like Chlorzoxazone are prescribed for virtually every pain complaint. Many are available over the counter without a prescription.

The typical pattern for back pain: you visit a doctor, get a strip of Diclofenac or Aceclofenac with a muscle relaxant, feel better in a few days, stop the medication, and the pain returns within weeks or months. You go back, get another strip. This cycle can repeat for years. Some patients take NSAIDs daily for months or years, often without medical supervision.

This pattern continues because the medication is doing exactly what it is designed to do: reducing inflammation and blocking pain signals. What it is not doing is addressing why your back hurts in the first place.

NSAIDs reduce inflammation and block the enzymes (COX-1 and COX-2) that produce prostaglandins, the chemicals that cause pain and swelling. This provides genuine relief. For acute pain from an injury, a short course of NSAIDs (3 to 7 days) can be appropriate and helpful. The problem is when they become the only treatment.

NSAIDs do not strengthen weak muscles. They do not improve mobility in stiff joints. They do not correct movement patterns that are overloading your spine. They do not address the deconditioning that comes from avoiding movement because of pain. They do not fix poor posture from sitting at a desk for 10 hours a day. In other words, they treat the symptom but not a single one of the causes.

This is why the pain returns when you stop. The underlying problem has not changed. You have just temporarily turned down the volume on the pain signal.

Short courses of NSAIDs are generally safe for most people. But the pattern of repeated or continuous use that many Indian patients follow carries real risks that are often not discussed.

Gastrointestinal damage is the most common side effect. NSAIDs reduce the protective mucus lining of the stomach and intestines. Long-term use increases the risk of gastric ulcers, GI bleeding, and perforations. In India, where many patients take NSAIDs on an empty stomach or combine them with other medications, GI complications are a major problem. Adding an antacid (Pantoprazole or Ranitidine) reduces but does not eliminate this risk.

Kidney damage is a less well-known but serious risk. Chronic NSAID use reduces blood flow to the kidneys and can cause acute kidney injury or chronic kidney disease, particularly in older adults, those with diabetes, or those who are dehydrated. Cardiovascular risk also increases with long-term NSAID use: studies have shown elevated risk of heart attack and stroke, particularly with Diclofenac.

These risks are compounded in India by the ease of over-the-counter access and the common practice of self-medicating for months without medical supervision.

The vast majority of back pain (over 90%) is classified as "non-specific," meaning it comes from muscles, ligaments, joints, and movement dysfunction rather than a specific structural problem like a fracture or tumour. For this type of pain, the evidence is unambiguous: exercise is the most effective treatment.

Specific exercises that strengthen the core and back muscles, improve spinal mobility, and correct movement patterns address the actual reasons your back hurts. This is not generic advice to "be more active." It is a targeted program based on your specific assessment, which differs for everyone. Someone with stiffness-dominant back pain needs different exercises than someone with instability-related pain.

The evidence also shows that patients who understand their pain, who learn that back pain is common, usually not dangerous, and responsive to exercise, recover faster than those who remain fearful and avoidant. This education component is a core part of physiotherapy that you will never get from a painkiller prescription.

You do not need to suffer through pain without any relief while starting physiotherapy. A sensible approach is to use painkillers strategically for short periods if needed (with medical guidance) while simultaneously starting an exercise-based treatment program that addresses the underlying cause.

The transition looks like this: during the first 1 to 2 weeks of physiotherapy, you may still use medication as needed for pain relief. As your exercises start to take effect and your pain reduces through addressing the cause, your need for medication naturally decreases. Most patients find that within 3 to 4 weeks of consistent exercise, their reliance on painkillers drops significantly.

Nuprana's online physiotherapy is designed for exactly this transition. Your programme includes an initial assessment, regular guided sessions, and a progressive home exercise plan. Your physiotherapist identifies why your back hurts, gives you the specific exercises to address it, and tracks your progress. The goal is to make painkillers unnecessary by fixing the problem, not just masking it.