• AAFP, ACP Release New Acute Pain Clinical Guideline

    Topical NSAIDs Get Strong Recommendation

    August 18, 2020, 9:10 a.m. Michael Devitt -- The AAFP and the American College of Physicians are announcing the release of a new joint clinical guideline. "Nonpharmacologic and Pharmacologic Management of Acute Pain from Non-Low Back, Musculoskeletal Injuries in Adults: A Clinical Guideline From the American College of Physicians and American Academy of Family Physicians," was published online Aug. 18 in Annals of Internal Medicine.

    jogger holding knee in pain

    The guideline is based on findings from two systematic evidence reviews. Overall, it recommends topical NSAIDs as first-line therapy for patients experiencing pain from these types of injuries. The guideline also recommends that clinicians not prescribe opioids except in cases of severe injury or if patients cannot tolerate first-line therapeutic options.

    "This guideline is not intended to provide a one-size-fits-all approach to managing non-low back pain," AAFP President Gary LeRoy, M.D., of Dayton, Ohio, said in a press release. "Our main objective was to provide a sound and transparent framework to guide family physicians in shared decision-making with patients."

    Guideline Development Process

    The guideline was developed by the ACP's Clinical Guidelines Committee and several representatives from the Academy in accordance with the ACP's guideline development process.

    In creating the guideline, the AAFP and the ACP used the results from a network meta-analysis on the comparative safety and efficacy of pharmacological and nonpharmacological treatments for acute musculoskeletal injuries in adults in the outpatient setting and a systematic review on the predictors of prolonged opioid use. Low back pain was excluded from the review because it was covered in a previous ACP guideline that the AAFP endorsed.

    Story Highlights

    The meta-analysis included 207 trials encompassing nearly 33,000 patients who experienced a variety of musculoskeletal injuries. The systematic review included 13 observational studies with a total of more than 13 million participants.

    Clinical outcomes were evaluated using the Grading of Recommendations Assessment, Development and Evaluation framework. Outcomes measured were pain, physical function, symptom relief, treatment satisfaction and adverse events.

    When evaluating the evidence on benefits and harms, the clinical guidelines committee reviewed the results from both direct evidence and the network meta-analysis using the highest certainty of the available evidence.


    Based on their analysis, the AAFP and the ACP issued the following recommendations for patients with acute pain from non-low back musculoskeletal injuries. In these patients, the organizations

    • recommend using topical NSAIDs with or without menthol gel as first-line therapy to reduce or relieve symptoms (including pain), improve physical function and improve treatment satisfaction (a strong recommendation based on moderate-certainty evidence);
    • suggest using oral NSAIDs to reduce or relieve symptoms (including pain) and improve physical function, or oral acetaminophen to reduce pain (a conditional recommendation with moderate-certainty evidence);
    • suggest using specific acupressure to reduce pain and improve physical function, or transcutaneous electrical nerve stimulation to reduce pain (a conditional recommendation with low-certainty evidence); and
    • suggest not using opioids, including tramadol (a conditional recommendation with low-certainty evidence).

    The organizations stated that topical NSAIDs were the only intervention that improved all outcomes in patients with acute pain from non-low back musculoskeletal pain.

    Topical NSAIDs also were among the most effective options for treatment satisfaction, pain reduction, physical function and symptom relief, and were not associated with a statistically significant increased risk of adverse effects.

    Oral NSAIDs were shown to be effective in reducing pain within two hours and one to seven days after treatment and were associated with greater likelihood of symptom relief. However, oral NSAIDs also were associated with an increased risk of gastrointestinal adverse events. Clinicians were advised to assess a patient's risk factors and treatment preferences when choosing between oral NSAIDs and acetaminophen.

    Specific acupressure improved pain at one to seven days post-treatment and improved physical function, but there was only low-certainty evidence that it improved pain within two hours of treatment. Similarly, there was low-certainty evidence that TENS improved pain within two hours or at one to seven days following treatment.

    Regarding opioids, the evidence reviews found high-certainty evidence that acetaminophen plus opioids reduced pain at one to seven days and also improved symptom relief. However, none of the other interventions reviewed (transbuccal fentanyl, tramadol, acetaminophen plus ibuprofen plus codeine or oxycodone) were associated with improvements in more than one clinical outcome.

    Additional evidence showed increased risks of neurologic and gastrointestinal adverse effects associated with opioid interventions, and combination therapies with opioids were more expensive than similar interventions without opioids. Based on these and other substantial potential harms, the guideline recommends that clinicians should avoid prescribing opioids except in cases of severe injury or patient intolerance of first-line therapeutic options.

    Family Physician Panelist Perspective

    Kenneth Lin, M.D., M.P.H., a professor in the Department of Family Medicine at Georgetown University Medical Center in Washington, D.C., represented the AAFP as a panelist in the guideline's creation. He told AAFP News that the guideline should raise awareness among FPs that for most patients with acute pain from non-low back musculoskeletal injuries, topical or oral NSAIDs are as effective, if not more effective, than opioids while producing fewer adverse effects.

    In particular, Lin said that the strong recommendation for topical NSAIDs will likely change the way many FPs currently treat patients with acute pain from these types of injuries.

    "I think that most FPs have tended not to think of topical NSAIDs as effective relief for acute musculoskeletal injury pain," Lin said. "Although topicals are currently more expensive than oral NSAIDs, hopefully the topical NSAID diclofenac becoming available over the counter will drive down prices for these therapies."

    The FDA approved a topical gel containing diclofenac for OTC use in February.

    Lin added that the Academy has numerous resources available to help FPs combat the opioid crisis, including a collection of content curated by American Family Physician and additional resources in the Patient Care section of the AAFP website.

    Finally, in patients with severe musculoskeletal injury pain who do require opioid treatment, Lin recommended that FPs prescribe shorter courses (e.g., three days instead of seven to 10) to reduce the likelihood of persistent opioid use.