Welcome relief in the treatment of pain

New guidelines highlight creams and gels as first-line therapies

In the year of COVID -19, a lot of other medical news flew under the radar. Yet another trial found no benefit to Vitamin D supplementation in older adults. A major trial of a high-dose omega-3 supplement was stopped early for lack of benefit, and there was another trial showing benefits for a combination polypill to treat cardiovascular disease risk factors.

But perhaps most practical for the general population are new guidelines from the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) about the treatment of acute musculoskeletal pain such as neck and shoulder pain.

Although easy to write off as a non-urgent medical problem, musculoskeletal injuries represent a significant burden of disease for the general population. In the U.S., they result in 65 million health care visits every year and cost the health system $176 billion in 2020. Most such injuries resolve within four weeks and in many circumstances special testing with X-rays or MRIS is unnecessary.

Nevertheless, treating the pain is important not just because it eases the suffering of the patient but it also allows them to continue with their daily activities without interruption.

However, treating pain is not easy. Opioids can be used effectively in specific situations, but their overuse has led to the current opioid crisis. The potential for patients to become addicted makes them problematic for most patients in most circumstances.

Over the counter non-opioid medications are preferable. Non-steroidal anti-inflammatory drugs (NSAIDS) are also effective at treating pain and at reducing the inflammation that goes along with most acute injuries. But NSAIDS have their own problems. They increase blood pressure, can cause stomach ulcers, can worsen kidney function and have been shown to be associated with an increased risk of heart attack. Their side effect profile makes them less than optimal, especially for older patients who may already have some underlying health problems.

While it might be acceptable to take NSAIDS like ibuprofen (Advil) or naproxen (Aleve) for short periods, repeated use over the long term is generally discouraged. Acetaminophen (Tylenol), which is not an anti-inflammatory, is sometimes preferable although it simply treats pain and does not reduce inflammation. But meta-analyses of the available evidence have shown that it is often not much better than placebo for conditions like low back pain and osteoarthritis of the hip and knee.

One treatment option often overlooked is topical NSAIDS. Applied as a cream or gel, they seem to be equally effective at treating pain as NSAIDS taken by mouth. A 2015 Cochrane review found they provide good levels of pain relief roughly on par with oral anti-inflammatories. Their main advantage was in the decreased risk of side effects. While there were more skin reactions with the topical creams, there were fewer serious side effects like stomach ulcers.

The important point to remember is that acute musculoskeletal pain is often self-limited and not life-threatening. Some patients may be able to get by with simple therapies like a heat wrap for their aching back, but others may require something more to get through the day. The goal is to improve pain without causing dangerous side effects, hence the growing awareness that opioids, despite their effectiveness, should be reserved for severe chronic cases where other treatments have failed.

Hence the new ACP/AAFP guidelines and their highlighting of topical NSAIDS as a first line therapy for patients with musculoskeletal pain. While they are not perfect, and may be insufficient for severe and more chronic forms of pain, they have two important qualities that made the ACP and AAFP recommend them as first-line therapies. They offer good effectiveness with fewer side effects than their oral counterparts, and that is nothing to sneer it when you are in pain.