New Guidelines for Treatment of Acute Musculoskeletal Pain to Avoid Use of Opioids

One of the common treatments for musculoskeletal pain is a prescription opioid; however, opioid use has become an epidemic in the United States. Between 1999 and 2018, the CDC reported close to 450,000 deaths connected to opioid overdoses. While prescriptions written for opioids have dropped in the last few years, there’s still a prevailing issue with addiction and overuse.

To help combat the epidemic and further reduce opioid prescriptions, the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) together released new guidelines to address pain management.


The Relationship Between Prescription Painkillers and the Opioid Epidemic

Prescription opioid pain medications have been one of the first methods of treating various types of pain for many years. They have also been a significant contributor to opioid drug overdose deaths since 1999. While the problem worsened from heroin and other opioids made in labs, such as fentanyl, the National Health Institute on Drug Abuse notes that prescription opioid use contributed to opioid-related deaths.

Prescription opioids come with the potential for misuse and abuse, and some people move from misusing or abusing prescription opioids to using heroin or fentanyl. Reducing the number of prescriptions for opioids is one important approach to solving the opioid epidemic.

The guidelines from the ACP and AAFP states that about 20% of outpatient visits for pain resulted in a prescription for an opioid. They also noted that opioids are commonly used as prescriptions for acute musculoskeletal injuries, which is a comprehensive term for injuries to bones, soft tissues, tendons, blood vessels, and nerves. They also found that, in 2015, two million people had an opioid use disorder that was related to prescription opioids.


New ACP & AAFP Guidelines to Help Curb the Epidemic

The ACP and AAFP put out joint guidelines recommending against the use of prescription opioids for pain relief, with certain exceptions. Specifically, the guidelines refer to acute pain resulting from non-low back pain due to musculoskeletal injuries. Examples of this type of injury include sprains, strains, whiplash, and soft tissue injuries. The guidelines, published on August 17, 2020 in Annals of Internal Medicine, recommend, with accompanying evidence, that physicians use alternative forms of pain relief.


Systematic Evidence Review for Alternate Methods of Pain Relief

The ACP and AAFP based their guidelines on a systematic evidence review that looked at the safety and efficacy of both pharmacological and non-pharmacological methods of addressing acute pain from specific musculoskeletal injuries in adults. They focused on non-low back injuries with treatment in an outpatient setting.

Non-pharmacological treatments that showed reduced pain included:

  • Massage therapy
  • Specific acupressure
  • Joint manipulation therapy
  • Transcutaneous electrical nerve stimulation (TENS)

Pharmacological treatments that showed reduced pain included:

  • Acetaminophen (Tylenol): Alone or combined with NSAIDs
  • Oral nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Topical NSAIDs: Alone or in addition to a menthol gel
  • A single dose of transbuccal fentanyl

Interventions found to be the most effective in a period of less than two hours were:

  • Acetaminophen
  • Acetaminophen plus the prescription NSAID, diclofenac
  • Oral NSAIDs
  • Topical NSAIDs alone or with menthol
  • Transbuccal fentanyl

The interventions found to be the most effective over a longer period of one to seven days included:

  • Acetaminophen
  • Oral NSAIDs
  • Topical NSAIDs
  • Acetaminophen plus the prescription muscle relaxant, chlorzoxazone
  • Specific acupressure
  • TENS

When looking at research on symptom relief, the review found moderate-certainty evidence of laser therapy providing relief, among some other treatments. Also, some of the pharmacological and non-pharmacological treatments showed some benefit for physical function and treatment satisfaction.

The interventions found to be the most harmful in this study include:

  • Acetaminophen plus opioids
  • Tramadol
  • Transbuccal fentanyl

Any use of opioids presents a risk for developing a drug dependency, and the prescription narcotic tramadol also has a high risk of dependency in addition to respiratory distress when taken in high doses.


An Overview of the ACP & AAFP Guidelines

Based on the systematic evidence review, the ACP and AAFP came up with a set of recommendations for treating acute pain from non-low back musculoskeletal injuries. In brief, they are:


Topical Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Topical NSAIDs should be the first line of treatment for acute non-low back musculoskeletal pain. Based on the review, the ACP and AAFP gave this treatment a grade of strong recommendation with moderate-certainty evidence.


2a. Oral NSAIDs or Oral Acetaminophen

In the guidelines outlined by the ACP and AAFP, the next line of symptom relief. The grade assigned for this method is a conditional recommendation with moderate-certainty evidence.


2b. Specific Acupressure or Transcutaneous Electrical Nerve Stimulation (TENS)

Specific acupressure or TENS therapy should be used as a next line of symptom relief. This comes with a grade of a conditional recommendation with low-certainty evidence.


Opioids, Including Tramadol, Should Not be Used

This guideline was given a grade of a conditional recommendation with low-certainty evidence.

Overall, the guidelines cautioned against the use of opioids for pain relief, except in certain situations. Instead, they supported the use of other pharmacological and non-pharmacological treatments. These alternatives to opioids showed pain relief in their systematic evidence review, and they have low or no risk of developing drug dependency or harmful side effects. These new guidelines, backed by evidence in their review, can guide physicians in treating pain without the use of harmful opioids and help further curb the opioid epidemic.


Non-Pharmacological Pain Relief From Aspen Laser

Pain relief is a big part of a healthcare provider’s job, and providing solutions that help reduce pain and improve patients’ quality of life is paramount. At Aspen Laser, we’re committed to helping healthcare providers offer non-pharmacological solutions for pain relief through our high-power laser therapy systems. Click the link below to view our extensive content library of how laser therapy is helping relieve pain throughout the body.

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