Pharmacologic Therapy for Acute Pain

 

Am Fam Physician. 2021 Jul ;104(1):63-72.

Related editorial: Management of Acute Pain from Musculoskeletal Injuries: Guidance for Family Physicians

Related practice guideline: Management of Acute Pain from Non–Low Back Musculoskeletal Injuries: Guidelines from AAFP and ACP

Author disclosure: No relevant financial affiliations.

Pharmacologic management of acute pain should be tailored for each patient, including a review of treatment expectations and a plan for the time course of prescriptions. Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatment options for most patients with acute mild to moderate pain. Topical NSAIDs are recommended for non–low back, musculoskeletal injuries. Acetaminophen is well tolerated; however, lower doses should be used in patients with advanced hepatic disease, malnutrition, or severe alcohol use disorder. Nonselective NSAIDs are effective but should be used with caution in patients with a history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease. Selective cyclooxygenase-2 NSAIDs are a more expensive treatment alternative and are used to avoid the gastrointestinal adverse effects of nonselective NSAIDs. Adjunctive medications may be added as appropriate for specific conditions if the recommended dose and schedule of first-line agents are inadequate (e.g., muscle relaxants may be useful for acute low back pain). For severe or refractory acute pain, treatment can be briefly escalated with the use of medications that work on opioid and monoamine receptors (e.g., tramadol, tapentadol) or with the use of acetaminophen/opioid or NSAID/opioid combinations. The opioid epidemic has increased physician and community awareness of the harms of opioid medications; however, severe acute pain may necessitate short-term use of opioids with attention to minimizing risk, including in patients on medication-assisted therapy for opioid use disorder.

Acute pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Acute pain lasts from a few days up to 12 weeks and is typically prompted by a specific event and caused by direct tissue damage that is likely to resolve. A person's perception of pain is controlled by biophysical factors, including sensory, emotional, cognitive, and social components.1 Pharmacologic management of acute pain should be tailored for each patient, and effective management may prevent the transition to chronic pain.2

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Topical nonsteroidal anti-inflammatory drugs are safe and effective for treating acute pain.18,19,20

A

Systematic review, consistent randomized controlled trials, evidence-based guidelines

Nonsteroidal anti-inflammatory drugs, acetaminophen, or a combination is an effective initial treatment approach for acute pain syndromes. Medication selection should be based on minimizing risks for the specific patient.13,17,23,25

A

Systematic reviews, consistent randomized controlled trials, clinical guidelines

Muscle relaxants are effective adjunctive medications for acute low back pain and neck pain.43,44

A

Systematic review, multiple randomized controlled trials

Gabapentinoids and antidepressant medications used to treat chronic neuropathic pain should not be used to treat acute pain.5356

B

Meta-analysis (gabapentinoids), systematic review (gabapentinoids and antidepressants), mixed results from high-quality studies (gabapentinoids)

Cannabinoids used to treat chronic neuropathic pain should not be used to treat acute pain.60

C

Mixed results from low-quality studies

Opioids should be used for no more than three days, only for severe or refractory acute pain, and only in combination with other medications.12,17,25,63,64

C

Expert consensus opinion, clinical guidelines


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Topical nonsteroidal anti-inflammatory drugs are safe and effective for treating acute pain.18,19,20

A

Systematic review, consistent randomized controlled trials, evidence-based guidelines

Nonsteroidal anti-inflammatory drugs, acetaminophen, or a combination is an effective initial treatment approach for acute pain syndromes. Medication selection should be based on minimizing risks for the specific patient.13,17,23,25

A

Systematic reviews, consistent randomized controlled trials, clinical guidelines

Muscle relaxants are effective adjunctive medications for acute low back pain and neck pain.43,44

A

Systematic review, multiple randomized controlled trials

Gabapentinoids and antidepressant medications used to treat chronic neuropathic pain should not be used to treat acute pain.5356

B

Meta-analysis (gabapentinoids), systematic review (gabapentinoids and antidepressants), mixed results from high-quality studies (gabapentinoids)

Cannabinoids used to treat chronic neuropathic pain should not

The Authors

show all author info

OCTAVIA AMAECHI, MD, is a faculty member at the Spartanburg (S.C.) Regional Family Medicine Residency, and an assistant professor in the Department of Family Medicine at the Medical University of South Carolina, Charleston....

MIRANDA MCCANN HUFFMAN, MD, MEd, is an associate professor in the Department of Family and Community Medicine at Meharry Medical College, Nashville, Tenn.

KALEIGH FEATHERSTONE, DO, completed residency training as chief resident at Spartanburg Regional Family Medicine Residency.

Address correspondence to Octavia Amaechi, MD, Spartanburg Medical Center – Center for Family Medicine 853 North Church St., Suite 510, Spartanburg, South Carolina 29303 (email: octavia.amaechi@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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