Musculoskeletal pain and painkillers

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Joint and muscle pain is probably the number one symptom that prompts people to seek the help of health professionals such as osteopaths. Musculoskeletal pain affects the bones, muscles, ligaments, tendons and nerves; it is commonly caused by physical injury, which can be widespread or localised in just one body part.

Acute episodes of pain after a sprain, strain or fall are the usual reasons people seek advice and treatment. Still, others visit the clinic seeking help for ongoing discomfort for persistent or chronic conditions. Approximately 50% of those with chronic pain have musculoskeletal problems, with a proportion developing chronic pain syndromes. The healthcare, economic and personal costs of managing pain are huge.

In the UK, there are a reported 2500 deaths a year related to the use of non-steroidal anti-inflammatory drugs (NSAIDs). Worryingly, 70-80% of the population mismanages medication for back or joint pain.

Since self-medication is epidemic, over-the-counter analgesics (painkillers) and anti-inflammatories (NSAID) are easy to buy. We must improve our knowledge of what drugs are safe to take; if in doubt, see your GP.


Speak to a pharmacist

Suppose you decide to self-medicate with an analgesic or anti-inflammatory for an injury and can’t get to your GP. In that case, it is advisable to talk with a local pharmacist, who is a highly trained, knowledgeable practitioner.

The current advice recommends taking a regular dose over 4 -5 days rather than taking an occasional pill now and then, as most medicines build up gradually and will be more effective if taken regularly.


Musculoskeletal pain management

Most symptoms usually improve within a few days or weeks and rarely routinely require specialist pain management. Initial treatment of acute pain is habitually a combination of physical therapy, such as osteopathy, staying active, and using simple analgesics with or without anti-inflammatory medications.


Pharmacotherapy in musculoskeletal pain

Pharmacotherapy is treatment using pharmaceutical drugs. The World Health Organisation (WHO) developed a three-step “protocol” for managing pain associated with malignancy; however, its general principles can be employed to manage musculoskeletal pain.

Stage 1. Simple analgesics; paracetamol and NSAIDs.

The problem with NSAIDs is gastric, renal, and anti-platelet side-effects, with the gastroprotective medication needed for some high-risk patients. There is a move away from long-term NSAIDs because of concerns over their side effects and toxicity.

Stage 2. Stronger medications;weak opioids.

Drugs, including codeine and dihydrocodeine and medication such as Tramadol, are weak opioids. These medicines effectively manage moderate pain, especially when combined with simple analgesics, e.g., paracetamol. However, they can lead to gastrointestinal problems; for this reason, lower doses combined with paracetamol may offer enhanced pain relief for some people.

Stage 3. Strong opioids: morphine and its derivatives.

Doctors often avoid prescribing strong opioids due to concerns around dependency and side effects. Nevertheless, it is essential to prescribe according to the patient’s needs to achieve the primary goal, to manage their pain effectively.


Other medications

For nerve-related (neuropathic pain) pain such as sciatica, drugs such as Amitriptyline, an older antidepressant regularly prescribed to treat pain (especially nerve pain) and its associated sleep problems. Other medicines in this category include Gabapentin and pregabalin. Finally, muscle relaxants may be helpful in the acute phase of a joint or muscle injury.


Caution

  • NSAIDs can cause side effects such as stomach irritation, so you should only use them as short courses, guided by your GP or specialist.
  • NSAIDs are generally not recommended for people with kidney disease, heart failure, cirrhosis, or for those who take diuretics.
  • NSAIDs may cause worsening asthma and related symptoms in some people. Please consult your GP if any of the above apply to you before self-medicating.

Final thoughts

While painkillers are often the first option for treating musculoskeletal pain, effective management usually means another intervention is needed besides taking pills. Of course, anti-inflammatory painkillers can be an effective first-line treatment with an acute injury, for example, a muscle sprain. Research shows that an entirely fresh approach is often beneficial in cases of chronic pain ( lasting longer than 12 weeks), one that tackles physical, psychological and social factors.

Ideally, a multidisciplinary approach might comprise health professionals such as manual or physical therapy experts, osteopaths, physiotherapists, and doctors specialising in pain management. Consulting a psychologist may be helpful for people with persistent chronic pain syndromes. A careful and thorough assessment is crucial to avoid chronicity; once diagnosed, prompt referral to other specialists for care or further investigation is the best practice. However, sadly, there can be long waiting times because of the constraints of the NHS, which is where osteopaths can help.


Please note:

This is for guidance only; it should not be regarded as a substitute for medical advice, examination or treatment given in person by an appropriately trained health professional.


References

Phillips, C. (2009). The Cost and Burden of Chronic Pain. British Journal of Pain, 3(1), pp.2-5.

Andersson HI, Ejlertsson G, Leden I et al. Musculoskeletal chronic pain in general practice. Studies of health care utilisation in comparison with pain prevalence. Scand J Prim Health Care 1999; 17: 87–92.

Gureje O, Von Korff M, Simon GE et al. Persistent pain and well-being: a World Health Organisation Study in Primary Care. JAMA 1998; 280: 147–151.

WHO: World Health Organisation. Cancer pain relief. WHO, Geneva, 1988.

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