While looking in today’s paper for inspiration for something to write about, I saw an advertisement claiming that the “Arthritis Pain Mystery” had been solved, and that the secret was “Horse Liniment.” Naturally there was something you can buy. The only corporate identification or images in the ad were the prominent trademarks of both Walgreens and RiteAid. I know something about arthritis, and I initially assumed that these two giant drugstore competitors had joined forces to bring this breakthrough to the public. At first it looked to me like the drugstores had placed the ad themselves.
Actually, the truth is that this advertisement caught my eye because is was one of a long series by many companies that make what is in my professional opinion overly sensational, misleading, and unsupported claims to be effective treatments for arthritis and other musculoskeletal ailments. I have always had to look hard and usually unsuccessfully for the grain of truth in these kinds of ads that might make them legal. No doubt the promoters of ARTH ARREST, “considered a medical miracle by some” had their ad reviewed by lawyers. It may well have passed such muster, but in my professional opinion, it fails the sniff test of ethical medical promotion. Any ad with the word “miracle” or which relys on anecdotal testimonials should wave a red flag. Even the big pharmaceutical companies do not make such claims, and they are not my ethical champions. When I read closer, I saw that the drugs were simply available at Walgreens and RiteAid. Both companies were apparently merely lending their good names to the promotion.
We could have some fun parsing through the ad and the additional material on the maker’s website. It was interesting to see the careful use of the English language. In brief, the product is a mixture of two chemicals long used in the joint liniment and cosmetic trades. It is only the trademark of the combination that is new: the product itself has apparently been around for a while. The two identified active agents (capsaicin and methyl nicotinate) belong to classes of drugs called rubefacients (red-making) and counter-irritants that attribute most of their potential effectiveness to causing new sensations in the skin that distract you from your muscle, tendon, or joint pain. Counterirritation has always been part of the ancient lore of treating animals, but this also has included blistering and fire-irons! I will concede that such remedies would make you forget you have arthritis. I do not know what the animals think.
There are a host of similar joint rubs containing capsaicin (the chemical from chili peppers that makes your mouth, skin, and guts burn) and other counter irritants available in both brand-name and generic versions. These have names you will recognize such as BenGay™, Icy Hot™, Zostrix™, or Capzasin™. You will find such products shelved together in the drugstore alongside the new “medical miracle,” but available in higher strengths, and cheaper. Full disclosure: I have used such products personally, and have suggested that some of my patients try them. A nice massage always feels good, no matter what you are rubbing in, especially if administrated by a willing partner. The smell and burning glow in the skin lend a little magic to the self-administered therapeutic process. Heating pads and hot water bottles also facilitate rest and comfort in afflicted parts for the same reasons.
Is there evidence for effectiveness?
I tried to find some evidence-based advice (i.e. objective verifiable evidence) in the medical literature that the touted drug was effective. In fact I could not find a single article in any published medical journal that even mentioned the name of the product. [Please let me know what I might have missed by responding in the comments section below. I wish to be fair. I would like to analyze any relevant study for us. I was on the editorial boards of both major American rheumatolgy journals and have had much experience evaluating the medical literature.] There have been a few studies of similar counter-irritant products, but these are thin on the ground, mostly of poor quality, and generally negative or only slightly positive in their results. Negative results are published much less often. Even if there is some minor therapeutic effect over placebo that makes people feel better, no one is really knows for sure how these agents might work.
There will always a few people in any study who improve, but the main reason I was able to stay in business as a rheumatologist was that most people with minor musculoskeletal problems get better by themselves no matter what you do (or do not do). Even people with bad arthritis alternate between good periods and bad ones. I always am willing to take credit for any improvement. As an example of the logic of this truism, consider this recommendation: “if you have poison ivy, rub cat urine on it and it will go away.” I bet a martini in your favorite Louisville bar that it will work 99.9% of the time. Try it yourself the next time you are clearing out your back lot, but talk to your doctor about it first. [This latter disclaimer is to protect me legally from the inevitable person who will believe anything that they read in an advertisement or blog.] To their credit, the makers of the new preparation provide a page on their website that they apparently use to convince drugstores and other retailers to stock their product. Not surprisingly, given that it was prepared for a different audience, the background information and claims are less hyperbolic. They even give a link to the Mayo Clinic website which says:
“Opinions differ on the effectiveness of over-the-counter topical pain medications. While many people say these products help relieve their arthritis pain, scientific research reveals only modest benefits. Some products work no better than placebo in relieving arthritis pain.”
This is a generous appraisal. What seems more realistic to me is the opinion of the Cochrane Reviews, the gold standard organization for analyzing the medical literature to determine whether various medical treatments actually work. Their most current conclusion is:
“The evidence does not support the use of topical rubefacients containing salicylates for acute injuries, and suggests that in chronic conditions their efficacy compares poorly with topical non-steroidal anti-inflammatory drugs (NSAIDs). Topical salicylates seem to be relatively well tolerated in the short-term, based on limited data. There is no evidence at all for topical rubefacients with other components.” [my emphasis] (Cochrane Database Syst Rev. 2009 Jul 8;(3):CD007403.)
What should you do personally?
If you want to try any of these joint rubs, I will not condemn you or even make fun of you. You have a wide choice of liniments available. Most, probably won’t hurt you. I have no confidence at all that they will help you any more than rest, heat, and self-administered physical therapy (such as gentle stretching so the area does not get stiff). You should do these things anyway. By all means try a little massage: baby lotion or baby oil will do fine. I personally take generic ibuprofen for my arthritis and minor injuries. Be careful with capsaicin-containing products like the one we are talking about– after all that is what defensive pepper sprays are made out of. Don’t get it in the wrong places like your eyes or crotch. If you want to try a counter-irritant, try a store-brand that should be less expensive.
What’s the point?
So why do I make a big deal out of joint rubs? You already know my feeling that medical marketing leads to unnecessary medical services that in the end we all have to pay for. You also know my feelings about overly sensational, misleading, or scare tactics in medical marketing. I am writing today about a $20 joint rub that is part of a $3.6 Billion global over-the-counter topical analgesic market. Yesterday I could have written about $20,000 coronary angioplasties that are still being done for stable angina when the best medical studies show that standard non-invasive treatment is just as good and will have to be administered anyway. Your tax dollars and insurance premiums are paying for somebody else’s Cadillac because in their personal judgment, surgery was better. Whether $20, $20,000, or even $200,000: the principle is the same. As long as we pool our resources to provide healthcare for a group of us, we have a collective right to expect that our money will be used wisely. I can guarantee you, that at the present time, much of your money is being squandered. I will be writing about this much more in the weeks to come.
Peter Hasselbacher, MD
February 13, 2012