Perspective from Brian A. Cole, MD, FAAOS
Perspective from Harrison Linder, MD
Disclosures: Fincher is president of ACP. LeRoy is president of AAFP.
August 17, 2020
4 min read
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ACP, AAFP recommend NSAIDs as first-line therapy for non-low back pain

Perspective from Brian A. Cole, MD, FAAOS
Perspective from Harrison Linder, MD
Disclosures: Fincher is president of ACP. LeRoy is president of AAFP.
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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.

The quote is: There are a multitude of both pharmacologic and nonpharmacologic options that should all be offered and tried first before relying on opioid pain medications. The source of the quote is: Harrison Linder, MD.

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.

Jacqueline W. Fincher
Jacqueline W. Fincher

“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.

Gary LeRoy
Gary LeRoy

“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.”