A Joint Effort: A Provider's Guide To Orthopedic Pain Options
Orthopedic Health Care Provider and Partner
For patients who suffer from bone or nerve-related pain, an orthopedic's expertise is important to keep them symptom-free with an active lifestyle. In addition to prescribed physical therapy and exercise, drug therapy for orthopedic conditions can relieve the pain, swelling and paresthesias due to various conditions, such as:
Drug Therapy for Orthopedic Conditions
While drug therapy is not the only pain treatment an orthopedic specialist can offer, it may provide significant relief and allow your patient to return to daily activities, allow the ability to participate in a much-needed physical therapy, and have an increased quality of life. Below is a list of drug classes commonly used for bone pain and other painful orthopedic conditions:
First Line Rescue: Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most common classes of drugs used by patients. In fact, for mild to moderate bone pain, this might be the only drug treatment needed. Common over-the-counter (OTC) names include: aspirin, ibuprofen (Advil, Motrin, Nuprin), and naproxen (Aleve).
In certain circumstances, you might want to prescribe a prescription agent if OTC agents aren't effective for your patient. These might include generic (and affordable) NSAIDs such as: diclofenac (Voltaren), meloxicam (Mobic), and celecoxib (Celebrex), a COX-2 inhibitor.
Protect Your Patients From NSAID Side Effects
Many patients require long-term use of NSAIDs for chronic pain. NSAIDs include these important precautions, with many contained in FDA boxed warnings like the one on diclofenac:
- Gastrointestinal pain or perforation, dyspepsia or hemorrhagic ulcers; high risk in the elderly per boxed warnings.
- Renal damage, decreased urine output, fluid retention, edema.
- Cardiovascular issues: Possibly fatal myocardial infarction, stroke, CHF, exacerbated hypertension, especially with long-term use, per boxed warning.
- Contraindication in CABG setting, per boxed warning.
- Allergic reaction/anaphylaxis.
- NSAIDs are not without important side effects, but can be quickly effective, safe, and affordable medications with proper patient education. If your patients are older or have risk factors for GI bleeding, consider combination of an NSAID with a proton-pump inhibitor like omeprazole or misoprostol, or use of celecoxib (Celebrex). In many older patients, use of NSAIDs should be avoided based on their risk overall factors.
Acetaminophen: Safer, In Some Cases
Non-narcotic drugs like the NSAIDs and even acetaminophen (Tylenol) are useful adjuncts to help control pain; however, acetaminophen does not lower inflammation like the NSAIDs. Some advantages to acetaminophen side effects that offer an advantage over NSAIDs for bone pain include:
- Lower renal risk
- Easier on the GI than NSAIDs
- Limited cardiovascular safety issues
However, it's important that patients do not exceed the recommended daily acetaminophen dose and avoid drinking alcohol to help prevent serious hepatotoxicity. Warn patients to check for acetaminophen in other prescription and over-the-counter (OTC) drugs and to avoid alcohol use. In January 2014, FDA required all prescription acetaminophen combination pain products to contain no more than 325 mg of acetaminophen to lessen overdose risk and liver injury; total doses should not exceed 3 to 4 grams per day.
Topical NSAIDs for Pain
Several guidelines, including the Beers Criteria, recommend against oral use of NSAIDs in older patients over 65 years due to a higher risk of GI bleeding. Topical NSAIDs in the form of solutions or gels are available for joint pain and might be a reasonable option. Topical diclofenac (Pennsaid, Flector Patch, Voltaren Gel) are available. Clinical studies suggest these agents are effective for osteoarthritis knee pain and may be as effective as that achieved with oral NSAIDs. However, if oral NSAIDs are used in older patients consider gastroprotective medications, too.
Red Hot Chili Peppers
Capsaicin is the active ingredient that gives the heat to a chili pepper. It has been used as a topical analgesic in over-the-counter (OTC) products such as Zostrix, Icy Hot Arthritis Therapy, and Salonpas to relieve pain in arthritis and for postherpetic neuralgia. Patients can buy these OTC products without a prescription at the pharmacy.
A capsaicin prescription patch known as Qutenza is now FDA-approved for postherpetic neuralgia, as well. Qutenza, applied by the health care provider, can provide up to 3 months of pain relief following a single one-hour application. Qutenza is not a narcotic medication and is unlikely to cause drowsiness or have drug interactions. If needed, treatments can be reapplied for your patients every three months.
Antidepressants: An Adjunct For Refractory Cases
Pain is hard on your patient's body -- and their mind. Changes in their normal daily activities can lead to frustration and even depression. In fact, 20% of people with chronic pain are also depressed. Plus, the inability to move without pain can make orthopedic treatments -- including physical therapy -- difficult to tolerate and slow down recovery. Antidepressants can lessen symptoms of pain, depression, and provide a more restful sleep. Common antidepressants used for orthopedic pain relief include:
- Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft).
- Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine (Cymbalta).
- Tricyclic antidepressants like amitriptyline (Elavil) and nortriptyline (Pamelor)
Be aware that antidepressants can lead to thoughts about self-harm and suicide in some patients, especially in teens, so careful monitoring is warranted. Be sure to run a drug interaction screen with all new medications prescribed to your patients; antidepressants are notorious for serious drug interactions.
Anticonvulsants: Nerve Pain Relief
Anticonvulsants, which inhibit central neurotransmitter release, have been shown in trials to be effective for postherpetic neuralgia, neuropathic pain, and fibromyalgia. Anticonvulsants are considered first line over opioids or tramadol for neuropathic pain management. Treatment examples include:
Corticosteroids: Local or Short-Term Relief
Corticosteroids can be taken by mouth or given by injection for joint pain and inflammation. Orally, treatment is usually a short-term tapering dose for one to two weeks. Long-term oral corticosteroids can lead to serious adverse effects including weight gain, lowered immunity, elevated blood glucose, GI ulceration, and corticosteroid-induced osteoporosis. Localized injections directly into the joint can provide pain relief over a longer period of time, up to six months, and more safely. Frequently used corticosteroids include:
Skeletal Muscle Relaxants
Skeletal muscle relaxants include drugs such as:
- Carisoprodol (Soma)
- Cyclobenzaprine (Flexeril)
- Tizanidine (Zanaflex)
- Metaxalone (Skelaxin)
- Methocarbamol (Robaxin)
- Baclofen (Lioresal)
Osteoporosis: A Risk of Fractures
Osteoporosis the thinning of bone tissue and loss of bone density over time, which can raise a patient's risk for a bone fracture. In fact, bones can fracture even during normal motions, such as bending over or coughing. Osteoporotic bone fractures commonly occur in the wrist, hip and spine.
A variety of drugs are FDA-approved to treat and prevent worsening of osteoporosis. Mechanisms include reducing bone loss while boosting calcium, or by altering the cycle of bone formation and breakdown. Common osteoporosis treatments include:
Hyaluronic acid is naturally present in joint fluid and acts as a lubricant and shock absorber to help joints slide more easily. In osteoarthritis sufferers, this fluid may get thin and not work as well, as commonly seen in patients with knee pain.
Hyaluronic acid derivatives (viscosupplementation agents) can be injected into the knee joint to help relieve discomfort and decrease pain for up to six months. These agents are sometimes used in patients who cannot tolerate NSAID side effects, or those awaiting joint surgery.Common examples include:
Chronic Pain Guidelines
Chronic, nonmalignant pain management is a specialized area that requires the clinical expertise of the treating physician. However, expert guidelines can help to answer many questions regarding opioids.
In early 2016, the FDA announced a extensive review of the agency’s approach to narcotic analgesics to guide clinicians in pain treatment choices. Plus, the CDC has issued guidelines for Prescribing Opioids for Chronic Pain, and Cochrane for Clinicians has published Opioid Therapy for Chronic Noncancer Pain.
Opioids: The Call to Limit Prescribing
Even though the recent call by the CDC and FDA to limit opioid use in patients with chronic pain is reasonable, some patients will still have severe pain requiring a narcotic-type medication. Using opioids is not a decision a health care provider should take lightly, as narcotic pain relievers can be habit-forming, abused, illegally diverted, and tied with many side effects like sedation, severe constipation, and nausea. For mild-to-moderate, short-term pain, other analgesics should be prescribed.
However, when needed, opioids may be combined short-term with other non-narcotic pain relievers, like acetaminophen or NSAIDs, in an effort to lower doses. Common examples of narcotic analgesics include:
Tramadol: Consider the Risk
Tramadol (Ultram, Ultram ER, ConZip, Rybix ODT, Ryzolt) is a commonly prescribed analgesic with partial action at the mu opioid receptor, plus serotonin and norepinephrine reuptake inhibition. When originally marketed, tramadol was thought to be at lower risk for dependence. However, since then it has been linked with drug abuse and misuse, addiction, and even fatal overdoses. Due to these issues, in 2014 all forms of tramadol were placed into schedule IV of the Controlled Substances Act (CSA).
Tramadol is related to other narcotics; combined alcohol use should be avoided. Psychological and physical dependence, drug-seeking behavior, addiction, and withdrawal have been documented. Plus, withdrawal may occur if tramadol is abruptly discontinued. The side effect profile is similar to other opioids, but seizure risk may be elevated in some patients.
Pain Management: It Takes A Team
Orthopedic pain control is not a one-step task. Pain management is a joint effort for your patient - not only with medications and physical therapy, but with a trusted, caring, and knowledgeable health care team. Doctors, nurses, pharmacists and physical therapists can work together to help identify, manage, and safely control pain.
Therapy should encompass a stepwise approach, utilizing multiple medications, if needed, to take advantage of additive mechanism of actions, lowered doses, and reduction of side effects. Opioid prescribing should be limited when possible. Caregivers, as well as patients, should be involved with pain management education, treatment plans and therapy goals.
Finished: A Joint Effort: A Provider's Guide To Orthopedic Pain Options
- The US Centers for Disease Control and Prevention (CDC). CDC Guideline for Prescribing Opioids for Chronic Pain. March 15, 2016. Accessed April 17, 2017 at http://www.cdc.gov/drugoverdose/prescribing/guideline.html
- Reuben DB, Alvanzo AA, Ashikaga T, Bogat GA, Callahan CM, Ruffing V, et al. National Institutes of Health Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain. Ann Intern Med. 2015;162:295-300. doi:10.7326/M14-2775. Accessed April 17, 2017 at http://annals.org/article.aspx?articleid=2089371
- Seehusen D. Opioid Therapy for Chronic Noncancer Pain. Cochrane for Clinicians. Am Fam Physician. 2010 Jul 1;82(1):40-42. Accessed April 17, 2017 at http://www.aafp.org/afp/2010/0701/p40.html
- American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 63:2227–2246, 2015. Accessed Accessed April 17, 2017 at http://onlinelibrary.wiley.com/doi/10.1111/jgs.13702/full
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- The American Academy of Pain Medicine. Use of Opioids for the Treatment of Chronic Pain. February 2013. Accessed Accessed April 17, 2017 at http://www.painmed.org/files/use-of-opioids-for-the-treatment-of-chronic-pain.pdf
- Huntzinger A. Guidelines for the Use of Opioid Therapy in Patients with Chronic Noncancer Pain. Am Fam Physician. 2009 Dec 1;80(11):1315-1318. Accessed April 17, 2017 at http://www.aafp.org/afp/2009/1201/p1315.html
- Rosenquist E. Overview of the treatment of chronic pain. Up To Date. Updated August 2016 at http://www.uptodate.com/contents/overview-of-the-treatment-of-chronic-pain