Musculoskeletal pain arises from the muscles, bones, joints, and connective tissue. Musculoskeletal complaints encompass conditions such as myalgias, tendonitis, bursitis, sprains, strains, and osteoarthritis. Location, signs, symptoms, onset, modifying factors, and treatments vary. Providers must ask appropriate questions to identify the types of pain for which patients are seeking treatment, to achieve a better understanding of their pain complaints, and to identify risks that preclude self-treatment. Treatment goals include decreasing the severity and duration of pain; restoring function of the affected area; preventing reinjury and disability; and keeping acute pain from becoming chronic, persistent pain. Key exclusion criteria include severe pain (greater than 6 on a scale of 1 to 10); pain that lasts more than 10 days; pregnancy; pain accompanied by nausea, vomiting, or fever; and pain in patients younger than age 2 years. Nonpharmacologic therapy consisting of rest, ice, compression, and elevation (RICE) along with nonprescription oral and/or topical analgesics can be used during the first 1 to 3 days after an injury. RICE therapy promotes healing and helps reduce swelling and inflammation associated with muscle and joint injuries. Heat therapy is an alternative for noninflammatory pain and may help with stiffness. Ease of use favors newer products, which can be worn on the affected area from 8 to 12 hours. Many patients use nonprescription analgesics for pain relief. The minimum age for use of most of these products is 12 years, but some products (particularly capsaicin products) specify 18 years and older. Factors that affect product selection include dosage form, ease of use, cost, and even odor of the preparation. Available dosage forms include solutions, liniments, gels, lotions, ointments, creams, and patches. Topical analgesics are approved for treatment of minor to moderate aches and pains of muscles and joints and are adjuncts to pharmacologic and nonpharmacologic therapies. Lidocaine, in concentrations of 0.5% to 4%, is available in a nonprescription cream and patches marketed for nerve pain. The mechanism of action includes inhibiting the conduction of nerve impulses. The FDA-approved time frame for topical analgesics is 7 days of use every 6 to 8 hours as needed, not to exceed three applications in 24 hours. Topical counterirritants provide a paradoxical pain-relieving effect by producing a less severe pain to counter a more intense one and are classified into four groups: rubefacients, those that produce a cooling sensation, those that cause vasodilation, or those that incite irritation without rubefaction. Literature on the efficacy of counterirritants is conflicting, and current studies are often lacking. Acetaminophen or NSAIDs such as aspirin, ibuprofen, and naproxen are often used for initial treatment of musculoskeletal injuries. Systemic analgesic therapy should be limited to 10 days of self-care use, and patients should seek appropriate medical care if the condition continues or worsens beyond this period. Refer to specific package labeling for details on dosing and safety issues. Management of acute back pain can include the use of nonpharmacologic treatments and nonprescription analgesics. Patients with subacute or chronic low back pain require medical evaluation before they initiate self-treatment. For treatment of osteoarthritis of the hip and knee, acetaminophen has been recommended historically by some organizations for first-line therapy, despite data suggesting that NSAIDs provide slightly better pain relief. However, chronic use of NSAIDs leads to more severe and prevalent adverse effects (e.g., nephropathy, GI ulcerations and bleeding, increased risk for cardiac events). Various professional organizations, such as the American College of Rheumatology, American College of Physicians, and the American Association of Orthopedic Surgeons, have guidelines that address specific conditions and therapies. Explain to patients who are eligible for self-treatment the expected benefits of medication, appropriate dose and administration schedule, application directions, potential adverse reactions, potential interactions, and self-monitoring techniques for assessing response. Counsel patients to prevent injuries by warming up and stretching muscles before physical activity, ensuring proper hydration, and wearing appropriate footwear. Daniel L. Krinsky, RPh, MS, owner, EduCare, LLC; and co-owner, PGx101.com. For more information, please see APhA’s Handbook of Nonprescription Drugs, available in print or online to subscribers of Pharmacy Library at www.pharmacist.com.
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Apr 1, 2020
Sonnet S Jonker + 1
