For Short Bouts of Acute Pain, Avoid Opioids, Guidelines Caution

Providers treating patients with acute pain from musculoskeletal injuries should avoid opioids, according to new guidelines.

The guidelines, Non-Pharmacological and Pharmacological Management of Acute Pain from Non-Low Back, Musculoskeletal Injuries in Adults: A Clinical Guideline are from the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP). The joint guideline was published Monday in Annals of Internal Medicine.

Acute pain is defined as pain lasting 4 weeks or less.

The first recommendation is for topical nonsteroidal anti-inflammatory drugs (NSAIDs), with or without menthol gel. Other options include oral NSAIDS, acetaminophen, specific acupressure, or transcutaneous nerve stimulation. The recommendations are based on an assessment of clinical outcomes using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system: pain (at ≤2 hours and at 1 to 7 days), physical function, symptom relief, treatment satisfaction, and adverse events.

The assessment was based on a review of 207 trials including 32,959 patients with musculoskeletal injuries; these types of injuries are among the most common and typically treated in outpatient settings.

The review showed that topical NSAIDs were among the most effective for pain reduction, physical function, treatment satisfaction, and symptom relief.

In addition, a separate review included an assessment on the predictors of prolonged opioid use in patients deemed low risk when used for these types of injuries. Low risk was defined as not being on disability or having indications of having any other substance use disorder.

The overall prevalence of prolonged opioid use for this group was 6% (95% CI, 4%-8%). However, moderate-certainty evidence showed certain factors increased the risk of prolonged opioid use:

• Greater physical comorbidity (absolute risk increase [ARI], 0.9%; 95% CI, 0.1%-1.7%)
• Age (ARI for every 10-year increase, 1.1%; 95% CI, 0.7%-1.5%)
• Past or present substance use disorder (ARI, 10.5%; 95% CI, 4.2%-19.8%)

In addition, low-certainty evidence from studies that could not be pooled showed that longer opioid use was linked with prescriptions lasting more than 7 days and higher morphine milligram equivalents per day.

In 2010, musculoskeletal injuries accounted for more than 65 million health care visits in the United States, with an estimated annual treatment cost of $176.1 billion in 2010.

"As a physician, these types of injuries and associated pain are common, and we need to address them with the best treatments available for the patient. The evidence shows that there are quality treatments available for pain caused by acute musculoskeletal injuries that do not include the use of opioids," said Jacqueline W. Fincher, MD, president, ACP, in a statement. "There are a number of recommended interventions that are not opioids to choose from, and topical NSAIDs should be the first line of treatment."

"This guideline is not intended to provide a one-size-fits-all approach to managing non–low back pain," said Gary LeRoy, MD, president of the AAFP. "Our main objective was to provide a sound and transparent framework to guide family physicians in shared decision making with patients."

The evidence reviews were conducted by researchers at McMaster University and funded by the National Safety Council; neither had a role in the guideline.