Treatment of acute musculoskeletal pain: new guidance

Topical nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended as a first-line therapy in new guidelines for treating acute non-back pain due to musculoskeletal injury in outpatients.

A clinical guide published by the American Guide College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) also provides oral NSAIDs, acetaminophen, specific acupressure, or percutaneous nerve stimulation to treat acute pain. Suggested use.

Guidelines Internal medicine annual report The use of opioids containing tramadol (Ultram) is not recommended unless serious injuries or primary treatment is not acceptable.

This guidance is endorsed by the AAFP and complements the 2017 ACP Guidelines for Acute Low Back Pain, which focuses solely on low back pain, said Gary LeRoy, AAFP’s GP in Dayton, Ohio.

“A new joint ACP and AAFP guideline has been developed to address other forms of acute musculoskeletal pain,” said Le Roy. “But the recommendations for low back pain and other musculoskeletal injuries are very similar, with strong recommendations for the use of opioids as a first-line treatment and NSAIDs as a preferred pharmacological option. Masu” MedPage today.

The guidance written by Amir Vaseem, MD, PhD, and MHA by ACP’s Vice President of Clinical Policy and colleagues is for all clinicians. It is based on two studies. A systematic evidence review of 207 drug and non-drug trials For effectiveness and safety, and Analysis of predictors of long-term opioid use After an acute musculoskeletal pain prescription incorporating 13 observational studies.

An evidence review by Jason Busse, DC, PhD and his colleagues at McMaster University in Hamilton, Canada, included approximately 33,000 patients with a median age of 34 years. About 48% of the studies included a mix of musculoskeletal injuries and 29% were enrolled Sprained, Whiplashed 6%, Muscular Tension 5%. They pointed out that there were no direct comparisons showing that one intervention was better than another.

Topical NSAIDs were the only interventions that improved all outcomes in patients with acute pain due to musculoskeletal injuries other than low back pain: treatment satisfaction (high-confidence evidence) and pain relief in less than 2 hours and 1 ~7 days, relief of function, and symptoms (evidence of moderate certainty). They were also not associated with a statistically significant increase in risk of side effects. Topical NSAIDs using menthol gel also improved pain in less than 2 hours (evidence of moderate certainty) and symptom relief (evidence of low certainty). The authors said that local treatment may not be appropriate in some cases, including severe injuries, as acute pain can vary widely.

Oral NSAIDs and acetaminophen reduced pain in less than 2 hours and 1-7 days, respectively, with evidence of moderate certainty. An increased risk of gastrointestinal (GI) adverse events such as bleeding, abdominal pain, constipation, diarrhea, indigestion, nausea and vomiting was associated with oral NSAIDs. Specific shiatsu improved and worked pain in 1-7 days (evidence of moderate certainty), but only less certain evidence that specific acupressure improved pain in less than 2 hours .. Evidence of low certainty suggests that transcutaneous electrical nerve stimulation (TENS) improved pain in less than 2 hours and 1-7 days.

Solid evidence has shown that acetaminophen and opioids reduce pain and improve symptom relief in 1-7 days. None of the other opioid interventions (transbuccal fentanyl, tramadol, acetaminophen + ibuprofen + codeine or oxycodone) were associated with improved multiple outcomes. Evidence of moderate to high certainty has shown that opioid intervention is associated with an increased risk of adverse neurological and gastrointestinal effects.

Similarly, an analysis of long-term opioid use after prescribing acute musculoskeletal pain by John Riva, DC, MSc and co-authors at McMaster University showed complaints of occupational injury, ankle sprains, back pain, or some acute pain. We have shown that the overall prevalence of long-term opioid use in low-risk populations is 6% (95% CI 4%-8%). 27% (95% CI 18%) when defined as the high-risk population-patients receiving compensation benefits for workers, veteran claimants, or patients with a high incidence of concurrent drug use disorders -37%).

Einar Ottestad, MD, an acute pain specialist at Stanford University School of Medicine, who was not involved in the study or development of guidelines, noted that it is important to note that this new guidance “indicates” not to use opioids. I pointed out.

“It’s not obligatory not to use opioids,” said Otestad MedPage today.. While most acute musculoskeletal pain is best managed with the strategies outlined in the guidance, “some data suggest that these drug therapies inherently carry more risk and are We support a significant reduction in pain scores using opioids,” he said.

“Opioids will continue to be appropriate for certain patients for a short period of time to allow recovery and rehabilitation,” Ottesta noted. “I hope the guidelines will help reduce the use of opioids for mild acute musculoskeletal pain, but they should remain a physician’s equipment.”

Clinical practice guidelines are “guide only, not applicable to all patients and all clinical situations,” said Qaseem and colleagues. “Thus, they are not intended to nullify the clinician’s judgment.”