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. The CDC reported 79,770 connected to opioid overdoses in 2022. The national opioid dispensing rate has declined since 2012, but dispensing rates in certain areas remain very high. In 3.6% of U.S. counties, enough opioid prescriptions were dispensed for every person to have one. Some counties had rates that were nine times higher than the national average. Dispensing rates for opioids vary widely across different states and counties. These areas should be targeted for intervention to reduce opioid addiction and overdose.

To help combat the epidemic and further reduce opioid prescriptions, the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) released guidelines to address musculoskeletal pain management (2020).

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 significantly contributed 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 a critical approach to solving the opioid epidemic.

The ACP and AAFP guidelines state that about 20% of outpatient visits for pain resulted in an opioid prescription. They also noted that opioids are commonly used as prescriptions for acute musculoskeletal injuries, a broad term for injuries to bones, soft tissues, tendons, blood vessels, and nerves. In addition, over 2.1 million people in the United States have an opioid disorder related to prescription opioids.

 “According to the National Library of Medicine, Opioid use disorders affect over 16 million people worldwide.”

New ACP & AAFP Guidelines to Help Curb the Epidemic

The ACP and AAFP put out joint guidelines against using prescription opioids for pain relief, with certain exceptions. Specifically, the policies 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 November 4th, 2022, in CDC Clinical Practice Guideline for Prescribing Opioids for Pain, 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 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 musculoskeletal pain included:

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

Pharmacological treatments that showed reduced musculoskeletal 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 fewer 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 more extended period of one to seven days include:

• 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 other treatments. Also, some pharmacological and non-pharmacological therapies showed benefits 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 of developing a drug dependency. The prescription narcotic tramadol also has a high risk of dependence and respiratory distress when taken in high doses.

Overview of the ACP & AAFP Guidelines for Musculoskeletal Pain

The ACP and AAFP developed recommendations for treating acute pain from non-low back musculoskeletal injuries based on the systematic evidence review. In brief, they are:

Topical Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Topical NSAIDs should be the first treatment for acute non-low back musculoskeletal pain. BASED ON THE REVIEW, the ACP and AAFP strongly recommended this treatment with moderate-certainty evidence.

2a. Oral NSAIDs or Oral Acetaminophen

In the guidelines outlined by the ACP and AAFP, the following line of symptom relief should be oral NSAIDs or acetaminophen. 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 the following 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.

The guidelines cautioned against 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 a low or no risk of developing drug dependency or harmful side effects. These new guidelines, backed by evidence in their study, can guide physicians in treating pain without using dangerous opioids and help further curb the opioid epidemic.

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Non-Pharmacological Musculoskeletal 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 a patient’s quality of life is paramount. Aspen Laser is committed to helping healthcare providers offer non-pharmacological solutions for musculoskeletal 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.