Acute Pain Management (5)

Interventions for Acute Musculoskeletal Pain
In addition to initial interventions such as providing information, assurance and advice to maintain reasonable activity levels, other options (non-pharmacological and pharmacological) exist for the management of acute musculoskeletal pain.

Non-pharmacological Interventions
Evidence for the effectiveness of a range of additional nonpharmacological (i.e. not involving medication) interventions for people with acute musculoskeletal pain is provided in the specific guideline topics. These include active, passive and behavioural therapies. Non-pharmacological interventions may be used in conjunction with pharmacological interventions (NHMRC 1999).

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Pharmacological Interventions
Simple Analgesics (Non-Opioid)
Paracetamol is considered an effective medication for mild to moderate pain and can be used in conjunction with opioids to manage more severe pain.
Generally, paracetamol has few side effects. Paracetamol is contraindicated for people with liver dysfunction. It can be used when NSAIDs are contraindicated. Patients should be warned of the risk of liver damage with the combination of alcohol and paracetamol.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
NSAIDs are considered effective in the management of mild to moderate pain. Concurrent use of opioids and NSAIDs may provide more effective analgesia than either of the drug classes alone. They may also reduce the side effects of opioid medications (NHMRC 1999).
The adverse effects of NSAIDs are potentially serious and all people cannot use them. NSAID use may result in gastro intestinal bleeding, renal dysfunction (particularly in older people), NSAID-induced asthma and impaired blood clotting.
It is imperative that contraindications are identified and respected (e.g. asthma, peptic ulcer) (NHMRC 1999). More recently, Cox-2 selective NSAIDs have become available. Evidence for their efficacy in a number of rheumatological
disorders has been demonstrated. Currently they are not subsidised for acute musculoskeletal pain in Australia.


Pharmacological Interventions
Simple Analgesics (Non-Opioid)
Paracetamol is considered an effective medication for mild to moderate pain and can be used in conjunction with opioids to manage more severe pain.
Generally, paracetamol has few side effects. Paracetamol is contraindicated for people with liver dysfunction. It can be used when NSAIDs are contraindicated. Patients should be warned of the risk of liver damage with the combination of alcohol and paracetamol.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
NSAIDs are considered effective in the management of mild to moderate pain. Concurrent use of opioids and NSAIDs may provide more effective analgesia than either of the drug classes alone. They may also reduce the side effects of opioid medications (NHMRC 1999).
The adverse effects of NSAIDs are potentially serious and all people cannot use them. NSAID use may result in gastro intestinal bleeding, renal dysfunction (particularly in older people), NSAID-induced asthma and impaired blood clotting. It is imperative that contraindications are identified and respected (e.g. asthma, peptic ulcer) (NHMRC 1999).
More recently, Cox-2 selective NSAIDs have become available.
Evidence for their efficacy in a number of rheumatological disorders has been demonstrated. Currently they are not subsidised for acute musculoskeletal pain in Australia.

Opioid Analgesics
Opioid analgesics bind to opioid receptors both within and outside the central nervous system and are used for management of severe pain. All opioid medications have the potential to cause side effects including constipation, urinary retention, sedation, respiratory depression, nausea and vomiting. Titration of medication should occur to optimise the response to the analgesic and to minimise side effects. The following points are highlighted in the NHRMC (1999) acute pain guidelines:
True allergy to opioids is uncommon; people may have side effects that are mistakenly referred to as ‘allergies’. There is no evidence that the use of opioids for the treatment of severe acute pain leads to dependence on, or addiction to, opioid medications.
The dosage should be tailored to each individual and the need for pain relief considered of greater importance than adhering strictly to a specific dose interval.

Muscle Relaxants
Muscle relaxants have the potential for side effects and show some short-term benefit in studies for low back pain. (Bigos et al. 1994; van Tulder et al. 1997).

Adjuvant Agents
There is no evidence to support the use of adjuvant agents, including antidepressants, anticonvulsants and oral corticosteroids, in the treatment of acute musculoskeletal pain.


Acute Pain Management (4) <||> Acute Pain Management (1)


taken from:
Australian Acute Musculoskeletal Pain Guidelines Group;2003; Evidence-based Management of Acute Musculoskeletal Pain; Bowen Hills: Australian Academic Press Pty. Ltd.