New Guidelines Recommend Topicals for Musculoskeletal Injuries

Diana Phillips

August 19, 2020

Opioids don't belong on the menu for managing acute pain from non–low back musculoskeletal injuries, except in cases of severe injury or when first-line therapies don't work, according to new guidance from the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP).

"Opioid therapies are associated with little to no benefit in this population, but with substantial harms, such as potential for longer term addiction and overdose," said Amir Qaseem, MD, vice president of clinical policy and the Center for Evidence Reviews at ACP in Philadelphia and lead author of the guideline, which is published online in Annals of Internal Medicine.

In addition to advising clinicians to avoid opioids, including tramadol, in most situations, the guideline recommends the following interventions for these patients.

  • Treatment with topical nonsteroidal anti-inflammatory drugs (NSAIDs) with or without menthol gel as first-line therapy for symptom and pain relief and to improve physical function and patient satisfaction with treatment

  • Treatment with oral NSAIDs

  • Treatment with specific acupressure alone or with transcutaneous electrical nerve stimulation (TENS)

"We found that topical NSAIDs with or without menthol gel are most effective and associated with pain reduction, symptom reduction, improvement in physical function, and better patient satisfaction," Qaseem said in an interview with Medscape Medical News. Although oral NSAIDs also reduce pain and relieve symptoms, "it is important to keep the harms associated with oral NSAIDs in mind, such as GI adverse events," he stressed. Acetaminophen is an option for patients with gastrointestinal (GI) or renal risk factors.

With respect to nonpharmacologic interventions, acupressure and TENS have been shown to effectively reduce pain, Qaseem said.

The recommendations are based on a systematic review of the comparative safety and efficacy of drug and nondrug management of acute pain lasting less than 4 weeks. The review included 207 trials that enrolled 32,959 participants and evaluated 45 treatments. Nearly half of the trials (48%) enrolled patients with a variety of musculoskeletal injuries; 29%, patients with sprains; 6%, patients with whiplash; 5%, patients with muscle strains; and the remainder, patients with a variety of injuries, including nonsurgical fractures and contusions. The median patient age among all participants was 34 years (interquartile range, 28 to 39 years). The outcomes evaluated included pain (at ≤2 hours and at 1 to 7 days), physical function, symptom relief, treatment satisfaction, and adverse events. The guideline committee only recommended interventions that resulted in improvements in at least two of these outcomes.

The authors also considered a second systematic review that included data from 14 cohort studies looking at predictors of prolonged opioid use. The studies enrolled patients with work injuries, ankle sprains, low back pain, or other sources of musculoskeletal pain.

Topical NSAIDs Lead the Pack

Of the various management options, topical NSAIDs were the only intervention that improved all outcomes, the authors report. "They were among the most effective interventions for treatment satisfaction (high-certainty evidence) and for pain reduction at less than 2 hours and at 1 to 7 days; function; and symptom relief," the guideline authors write. Further, the treatment did not increase patients' risk for adverse effects.

Topical NSAIDs plus menthol gel also improved pain at less than 2 hours and relieved symptoms, although no evidence suggested that the combination provides additional benefit over topical NSAIDs alone. Even so, because the combination is unlikely to increase harm, "offering the combination therapy as another treatment option is reasonable," according to the authors.

Several interventions improved only one outcome and as such did not meet recommendation criteria. These included massage therapy, acetaminophen plus ibuprofen plus codeine, and transbuccal fentanyl, all of which were linked to reduced pain at less than 2 hours; acetaminophen plus chlorzoxazone and ibuprofen plus cyclobenzaprine, which were associated with low-certainty evidence for pain improvement at 1 to 7 days; and laser therapy, which was associated with symptom relief.

With respect to the recommendation against opioid therapy, only one of five interventions showed improvements in more than one outcome. "High-certainty evidence showed that acetaminophen plus opioids reduced pain at 1 to 7 days and improved symptom relief; it also reduced pain at less than 2 hours, but this effect was small and not clinically important," the authors write. In addition to large increased risks for neurologic and GI adverse effects, many patients prescribed opioids continued long-term use, they note.

The guideline committee members concluded that the potential harms associated with opioid use outweighed the benefits, noting that both longer prescribing periods (>7 days vs 1 to 3 days) and higher daily morphine milligram equivalents were predictors of prolonged use. "Combination therapies with opioids also cost more than similar interventions without opioids, and many effective nonopioid alternatives exist for the management of acute pain," they write.

The recommendations against opioid use is a departure from recently published guidelines for pain management in acute musculoskeletal injury published by the Orthopaedic Trauma Association (OTA) Musculoskeletal Pain Task Force, which don't address the use of topical NSAIDs. However, regarding opioids, this task force recommended the "lowest effective immediate release opioid dose for the shortest period possible."

Opioids are commonly used to treat severe pain, but there is little evidence on their use in the short-term setting for acute injury, according to Joseph R. Hsu, MD, who was lead author of the OTA guidelines. As noted in the ACP guideline, some circumstances warrant opioid use in this population, but because of the potential for misuse, "the lowest dose for the shortest period should always be the approach," said Hsu, from the Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina. The OTA guidelines include specific recommendations for limiting opioid prescribing risks, such as adherence with state and local drug monitoring programs and opioid education for patients and providers.

The most effective pain management strategies are often multimodal, Hsu stressed. In addition to drug treatment, psychosocial interventions can reduce anxiety and improve pain coping, and physical strategies, such as massage and TENS, can reduce pain and symptoms, he noted.

According to Qaseem, the new ACP guideline is the first issued by the organization on this topic. "We expect the recommendations will be highly informative [to providers], from the benefits of topical NSAIDs to highlighting issues around opioids."

The evidence reviews for the ACP/AAFP guideline were conducted by McMaster University and funded by the National Safety Council. Dr Hsu reports no conflicts.

Ann Intern Med. Published online August 18, 2020. Guideline full text, Systematic review (management of acute pain) abstract, Systematic review (prolonged opioid use) abstract

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