The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) have released a new clinical guideline on the management of acute pain associated with non-low-back, musculoskeletal injuries in adult outpatients. Evidence-based recommendations covering both pharmacologic and nonpharmacologic treatment strategies were included in the joint guidelines published in a the Annals of Internal Medicine.1
Formation of the Guideline
This new ACP/AAFP guideline was based on a network meta-analysis of studies comparing the efficacy and safety of pharmacologic and nonpharmacologic treatments for acute musculoskeletal injuries as well as a systematic review and meta-analysis of predictors of prolonged opioid use following an initial prescription for acute musculoskeletal injuries.2,3 In the first meta-analysis on pharmacologic and nonpharmacologic treatments, there were a total of 207 studies including 45 therapies administered across 32,959 patients with acute musculoskeletal injuries. The second meta-analysis included 14 observational cohorts with 13,263,393 patients who were prescribed opioids for acute musculoskeletal injuries.
Topical Nonsteroidal Anti-Inflammatory Drugs
Topical nonsteroidal anti-inflammatory drugs (NSAIDs) were the only treatment option that improved all outcomes in patients with acute pain associated with non-low back, musculoskeletal injuries. The included studies showed that topical NSAIDs resulted in pain reduction at ≤2 hours and at 1–7 days. The use of topical NSAIDs did not confer a significant increase in the risk for adverse events. Overall, topical NSAIDs were shown to reduce or relieve pain, improve physical function, and increase treatment satisfaction among patients. Due to this evidence, the ACP/AAFP guideline made a strong recommendation that clinicians consider topical NSAIDs for these patients.
NSAIDs, with or without menthol gel, should be considered a first-line treatment strategy to reduce or relieve pain symptoms associated with the injury. Studies have shown that this combination strategy can also improve pain in <2 hours and produce symptom relief. There is no evidence to suggest that the combination is superior to topical NSAIDs alone.
It is important to note that in cases of severe injury, the guideline suggests topical NSAIDs may not appropriate as a first-line approach.
Oral NSAIDs are also recommended for patients with acute pain from non-low back, musculoskeletal injuries. Similar to topical NSAIDs, oral NSAIDs may also help reduce pain at <2 hours and improve physical function. This intervention may increase the risk for gastrointestinal adverse events, including bleeding, stomach pain, constipation, nausea, and vomiting.
Oral acetaminophen was also recommended for pain reduction; it received a conditional recommendation based on low-certainty evidence. Because oral NSAIDs and oral acetaminophen do not differ substantially in terms of costs, patient risk factors for gastrointestinal and renal events as well as patient treatment preferences should be assessed.
Available evidence suggests acupressure may be helpful for reducing pain and physical function. In some studies, specific acupressure improved pain between 1 -7 days and also improved physical function. Low-certainty evidence suggests that specific acupressure improves pain in <2 hours.
Based on the limited number of studies available, the ACP/AAFP made a conditional recommendation in the guideline for the use of specific acupressure to reduce pain and improve physical function in patients with acute pain from non-low back, musculoskeletal injuries. Additionally, the guideline also recommends transcutaneous electrical nerve stimulation for pain reduction.
Studies demonstrated that acetaminophen, when combined with opioids, can reduce pain and improve symptom relief. Opioids were also associated with pain reduction within <2 hours, but the meta-analysis found that this effect was “small and not clinically important.”
Treatment with transbuccal fentanyl, tramadol, acetaminophen plus ibuprofen/codeine or acetaminophen plus oxycodone was not associated with improvements in >1 outcome. Additionally, studies found that treatment with opioids conferred increases in the risk of GI and neurologic adverse events. Predictors for prolonged opioid use included longer prescribing periods and higher morphine milligram equivalents per day.
As the opioid epidemic continues to surge, the guideline specifically recommends against the use of opioids, including tramadol, for treating acute pain associated with non-low back, musculoskeletal injuries. Avoidance should be practiced at all costs, except in cases of severe injury or intolerance of first-line therapies, as opioids “are associated with substantial potential harms with little or no benefit and are associated with longer-term addiction and overdose,” the guideline authors wrote.
- Qaseem A, McLean RM, O’Gurek D, et al. Nonpharmacologic and pharmacologic management of acute pain from non–low back, musculoskeletal injuries in adults: A clinical guideline from the American College of Physicians and American Academy of Family Physicians. Ann Intern Med. Published online August 17, 2020. doi:10.7326/M19-3602
- Busse JW, Sadeghirad B, Oparin Y, et al. Management of acute pain from non–low back musculoskeletal injuries: A systematic review and network meta-analysis of randomized trials. Ann Intern Med. Published online August 17, 2020. doi:10.7326/M19-3601
- Riva JJ, Noor ST, Wang L, et al. Predictors of prolonged opioid use after initial prescription for acute musculoskeletal injuries in adults: A systematic review and network meta-analysis of observational studies. Ann Intern Med. Published online August 17, 2020. doi:10.7326/M19-3600