ACP, AAFP recommend NSAIDs as first-line therapy for non-low back pain
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Physicians should encourage adults to use NSAIDs, particularly topical ones, to treat acute non-low back pain that stems from musculoskeletal injuries, according to a new guideline from the ACP and American Academy of Family Physicians.
The organizations recommend against the use of opioids among most patients in this setting.
Researchers conducted a meta-analysis of 207 studies with 32,959 patients to evaluate pharmacological and nonpharmacological pain treatments using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system, which assesses pain (at 2 hours or less and at 1 to 7 days), physical function, symptom relief, treatment satisfaction and adverse events. The study participants were treated for sprains, whiplash, muscle strain, nonsurgical fracture and contusion treatments.
“These types of injuries and associated pain are common, and we need to address them with the best treatments available for the patient,” Jacqueline W. Fincher, MD, ACP president, said in a press release.
The researchers also conducted a systematic review of 14 cohorts that included 13,263,393 patients to evaluate predictors of prolonged opioid use.
Based on the analysis, the researchers recommend:
- using topical NSAIDs with or without menthol gel (strong recommendation; moderate-certainty evidence);
- using oral NSAIDs (conditional recommendation; moderate-certainty evidence);
- using specific acupressure to reduce pain and improve physical function (conditional recommendation; low-certainty evidence);
- using transcutaneous electrical nerve stimulation to reduce pain (conditional recommendation; low-certainty evidence); and
- not using opioids, including tramadol (conditional recommendation; low-certainty evidence).
A tailored approach to treating non-low back pain is also appropriate, according to AAFP President Gary LeRoy, MD.
“This guideline is not intended to provide a one-size-fits-all approach to managing non-low back pain,” he said in a press release. “Our main objective was to provide a sound and transparent framework to guide family physicians in shared decision making with patients.”
The recommendation, published in Annals of Internal Medicine, also said opioids should only be prescribed to patients without a history of substance use disorder who have “severe injury or intolerance of first-line therapies.”
In the systematic review, the overall prevalence of prolonged opioid use after musculoskeletal injury in “high-risk” patients (e.g., patients receiving workers’ compensation benefits, Veterans Affairs claimants or patients with high rates of concurrent substance use disorder) was 27% (95% CI, 18–37). The prevalence among low-risk populations was 6% (95% CI, 4–8).
Researchers also found moderate-certainty evidence of an association between persistent opioid use with older age (absolute risk increase [ARI] for every 10-year increase = 1.1%; 95% CI, 0.7–1.5), physical comorbidity (ARI = 0.9%; 95% CI, 0.1–1.7), and past or current substance use disorder (ARI = 10.5% 95% CI, 4.2–19.8%). There is low-certainty evidence that indicates an increased risk for persistent opioid use with prescriptions lasting more than 7 days (ARI ranged from 2%-9%) and higher morphine milligram equivalents per day (ARI ranged from 2%-13%, according to the researchers.
“Our study also has limitations, including imprecision for the prevalence of prolonged opioid use among high-risk populations and some risk of bias for most studies," they wrote. “Future research would benefit from prospective studies in which both the initial prescription for, and continued use of, opioids was confirmed to be associated with an acute musculoskeletal injury.”
Perspective
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Brian A. Cole, MD, FAAOS
Several years ago, I traveled to Lyon, France, to share surgical techniques with my French colleagues. Although many of the techniques that we used were the same, the one thing that was significantly different was their use of high dosages of ibuprofen and Tylenol for the treatment of postoperative pain for lumbar fusions.
Several years later, because of the opioid crisis, we began experimenting with similar protocols and we were pleasantly surprised at how effective these methods were. The clinical information released by the ACP and American Academy of Family Physicians further validates the fact that a good majority of acute pain will resolve in a short period of time and can be very effectively treated with NSAIDs, Tylenol and topical preparations.
While the evidence clearly demonstrates effectiveness of this form of treatment for non-low back pain musculoskeletal injuries, the major task at hand is to educate the public that most things can be treated without narcotic medication and we need to also manage their expectations of pain. We also now understand the dangers of prolonged use of opioid medication. Opioids have not shown a great benefit and in fact can cause harm. They should be avoided at all costs.
Perspective
Back to TopHarrison Linder, MD
It is no secret that our country is amid an opioid pandemic. The ACP and AAFP recommendations are perfectly reasonable and completely in line with current CDC guidelines.
While prescribing rates have gone down in recent years, rates of opioid misuse and overdose continue to trend in troubling directions. Access to opioids is a multifactorial problem, but for many people, their first dose of opioids occurs in relation to an episode of acute pain.
Multiple studies, including the Riva study referenced here, have shown that with increasing dose and duration of initial opioid prescription, rates of potential misuse and addiction also go up. It is for this very reason that the CDC, and now the ACP and AAFP, strongly recommend against use of opioids for treatment of acute pain. There are a multitude of both pharmacologic and nonpharmacologic options — acetaminophen, NSAIDs, muscle relaxers, membrane stabilizers, physical therapy, chiropractic, interventional measures — that should all be offered and tried first before relying on opioid pain medications.
While opioids certainly have a role in medicine, and can be particularly helpful with uncontrollable acute pain, they should remain far from the front lines and used only in exceptional circumstances.
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