Analgesics For Musculoskeletal Pain Summary Version Feb 2018

Analgesics for
musculoskeletal
pain
Fremantle Broome Sydney

1
Pain
o Nociceptive pain
o Neuropathic pain
o Due to a lesion or disease of the somatosensory nervous system
o Nociplastic pain
o Sensitization (amplification)
o Modulation
o Allodynia
EJ Visser Churack Chair UNDA 2018 copyright 2

Aims of
analgesia
o Pharmacotherapy: part of a multimodal pain Mx approach
o Acute pain relief
o acute to chronic pain transition
o functional rehabilitation (physiotherapy)
o risk of adverse effects
o chemical coping, addiction
o Mx chronic pain
Lets review the drug cupboard
Paracetamol
o Not sure how paracetamol works?

o COX-2, ‘cannabinoid’, serotonin?
o Maximum 8 per day

o Mainstay analgesic in most pain protocols
o No good for acute or chronic pain (Cochrane)
o individual responders
o older patients
o Combination paracetamol analgesics are more effective

Analgesia league table
NNT
o Celecoxib 400 2
o Ibuprofen 400 2.5
o Paracetamol 500 + ibuprofen 200 1.8
o Paracetamol 650 + tramadol 75 2.6
o Panadeine forte 60/1000 3
o Paracetamol 1000 4
o Oxycodone 5 mg 4
o Tramadol 100mg 5
o Codeine 60mg 17
NSAIDs & coxibs
o NSAIDS: ibuprofen, aspirin
o COXIBS: celecoxib (COX-2 selective)
o Anti-inflammatories
o Prostaglandin synthesis (COX)
o Good prostaglandins (housekeeping)
o Renal & gastric risk Gut Airway
o Cardiovascular risk Kidney Bone healing
Vessels Platelets Tissue healing

o Bleeding risk
NSAIDs & coxibs
o Celecoxib
o Ibuprofen, naproxen, diclofenac
o Effective for acute pain (NNT <3)
o ≤7 days
o Not for chronic pain
o Rapid-acting formulations ARE better
o Side effects (belly, bladder, bleeding)

NNT
o Celecoxib 400 2
o Ibuprofen 400 2.5
o Oxycodone 5 mg 4
o Tramadol 100mg 5
o Codeine 60mg 17
Tramadol
o Opioid, noradrenaline, serotonin

o Acute pain Serotonin
o Neuropathic pain (NNT 4) Noradrenaline

Opioids
o Respiratory depression & constipation
o Addiction (S4)
o Ineffective in 10% (prodrug, 2D6 enzyme)
o Renal accumulation, seizures, interactions, serotonin
NNT
o Celecoxib 400 2
o Ibuprofen 400 2.5
o Oxycodone 5 4
o Tramadol 100 4
o Codeine 60 15
Tapentadol (Palexia)
o ‘Weak’ opioid (S8) & noradrenaline analgesic
o Similar to tramadol without serotonin
o Side effects
o Acute pain
o Neuropathic pain
o Chronic pain
Opioids for chronic pain
o Poor risk vs benefit

o Don’t work well (NNT = 8, NNH = 4) (Level I)
o Risk of adverse effects
o classical side effects, tolerance, hyperalgesia, overuse, addiction
o Contraindicated in non specific spinal pain, fibromyalgia
o OK to trial in >60s with spondylosis or OA joint pain
o 3Ts: tramadol SR, tapentadol SR, transdermal buprenorphine
o Ceiling dose is ≤ 60 mg oral morphine equivalents/day
13
Combination analgesics
o For acute pain only
o Paracetamol 500 mg/ ibuprofen 200 mg (OTC)
o Paracetamol 325 mg/ tramadol 37.5 mg (Zaldiar) (script)
o Paracetamol 500 mg/ codeine 30 mg (script)
o Ibuprofen 200 mg/ codeine 12 mg (Nurofen plus) (script)

NNT
o Celecoxib 400 2
o Ibuprofen 400 2.5
o Oxycodone 5 4
o Tramadol 100 5
o Codeine 60 17
Antidepressants & anticonvulsants
o NOT effective for nociceptive pain
o Duloxetine (SNRI) is moderately effective (noradrenaline effect)
o Chronic LBP & knee pain
o Neuropathic pain (NNT 4)
o Pregabalin, gabapentin
o Not effective for LBP
o Radicular leg pain?

Other analgesics
o Topical NSAIDs
o OA knee, hands, enthesopathy, tendonopathy
o Topical capsaicin cream

o OA knee, hands
o Menthol 4% gel
17
Steroids
o Oral (prednisolone)
o Acute inflammatory arthritis, tendonitis, enthesitis, myositis
o Early CRPS?
o Acute radiculopathy?
o Injection
o Radicular leg pain (transforaminal epidural)
o Knee, hip, shoulder, facet, SIJ, soft tissues
Distal limb
injuries
Vitamin C 1000 mg/d for 4 weeks
 CRPS
O2 free radical scavenger
 neurogenic inflammation

Sleep &
supplements
o Sleep
o Melatonin, valerian, lavender
o Amitriptyline, pregabalin
o Anti-inflammatories
o Curcumin
o PEA (lecithin nutraceutical)
o Chondroitin & glucosamine

Cutting
edge?
o Neuroimmune & glial modulators
o Fibromyalgia, CFS, CRPS
o Melatonin
o Minocycline (antibiotic)
o Metformin (diabetes)
o Naltrexone

Controversies
o Codeine
o Cannabinoids
o Benefits < risks
o NNT 15 for both
o Individual responders?
o Muscle spasms
o Orphenadrine or baclofen (diazepam*) for muscle spasms
Acute musculoskeletal pain
o Comfort measures (heat)
o Combination paracetamol/ibuprofen prn (≤ 4 days)
o Severe…
o Celecoxib 100-200 mg bd (≤ 7 days)
o Combination paracetamol/tramadol or codeine prn OR…
o IR tapentadol or oxycodone prn
o ≤ 4/24 prn, ≤ 4 x daily, ≤ 4 days

Acute severe radicular pain
o Neuropathic pain (nociceptive, muscle spasms)
o Analgesics are poorly effective (level I)
o Tramadol, tapentadol or oxycodone
o Pregabalin
o Steroids (transforaminal injection or oral)
o Natural history; improvement in 3-6 months

Thank you

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Analgesics for

Fremantle Broome Sydney

EJ Visser Churack Chair UNDA 2018 copyright 2

o Pharmacotherapy: part of a multimodal pain Mx approach

o Acute pain relief

o acute to chronic pain transition

o functional rehabilitation (physiotherapy)

o risk of adverse effects

o chemical coping, addiction

o Not sure how paracetamol works?

o Maximum 8 per day

o Combination paracetamol analgesics are more effective

o Cardiovascular risk Kidney Bone healing

Vessels Platelets Tissue healing

o Ibuprofen, naproxen, diclofenac

o Effective for acute pain (NNT <3)

o Not for chronic pain

o Rapid-acting formulations ARE better

o Side effects (belly, bladder, bleeding)

o Opioid, noradrenaline, serotonin

o Neuropathic pain (NNT 4) Noradrenaline

o ‘Weak’ opioid (S8) & noradrenaline analgesic

o Similar to tramadol without serotonin

o Poor risk vs benefit

o Paracetamol 500 mg/ ibuprofen 200 mg (OTC)

o Paracetamol 325 mg/ tramadol 37.5 mg (Zaldiar) (script)

o Paracetamol 500 mg/ codeine 30 mg (script)

o Ibuprofen 200 mg/ codeine 12 mg (Nurofen plus) (script)

o Neuropathic pain (NNT 4)

o Radicular leg pain?

o Topical capsaicin cream

Vitamin C 1000 mg/d for 4 weeks

EJ Visser Churack Chair UNDA 2017 copyright 19

o Melatonin, valerian, lavender

o PEA (lecithin nutraceutical)

o Chondroitin & glucosamine

EJ Visser Churack Chair UNDA 2017 copyright 20

o Neuroimmune & glial modulators

o Fibromyalgia, CFS, CRPS

EJ Visser Churack Chair UNDA 2017 copyright 21

o NNT 15 for both

o Combination paracetamol/ibuprofen prn (≤ 4 days)

o Celecoxib 100-200 mg bd (≤ 7 days)

o Combination paracetamol/tramadol or codeine prn OR…

o IR tapentadol or oxycodone prn

o ≤ 4/24 prn, ≤ 4 x daily, ≤ 4 days

o Neuropathic pain (nociceptive, muscle spasms)

o Analgesics are poorly effective (level I)

o Tramadol, tapentadol or oxycodone

o Steroids (transforaminal injection or oral)

o Natural history; improvement in 3-6 months

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