Guideline Recommends Topical Pain Relievers for Muscle Aches and Joint Sprains

By Pat Anson, PNN Editor

A new guideline for primary care physicians recommends against the use of opioid medication in treating short-term, acute pain caused by muscle aches, joint sprains and other musculoskeletal injuries that don’t involve the lower back.

The joint guideline by the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) – which collectively represent nearly 300,000 doctors in the U.S. – recommends using topical pain creams and gels containing non-steroidal anti-inflammatory drugs (NSAIDs) as first line therapy. Other recommended treatments include oral NSAIDs, acetaminophen, specific acupressure, or transcutaneous nerve stimulation (TENS).

Musculoskeletal injuries, such as ankle, neck and knee injuries, are usually treated in outpatient settings. In 2010, they accounted for over 65 million healthcare visits in the U.S., with the annual cost of treating them estimated at over $176 billion.

"As a physician, these types of injuries and associated pain are common, and we need to address them with the best treatments available for the patient. The evidence shows that there are quality treatments available for pain caused by acute musculoskeletal injuries that do not include the use of opioids," said Jacqueline Fincher, MD, president of ACP.

Opioids, including tramadol, are only recommended in cases of severe injury or intolerance to first-line therapies. While effective in treating pain, the guideline warns that a “substantial proportion” of patients given opioids for acute pain wind up taking them long-term.   

The new guideline, published in the Annals of Internal Medicine, recommends topical NSAIDs, with or without menthol, as the first-line therapy for acute pain from non-low back, musculoskeletal injuries. Topical NSAIDs were rated the most effective for pain reduction, physical function, treatment satisfaction and symptom relief.

Treatments found to be ineffective for acute musculoskeletal pain include ultrasound therapy, non-specific acupressure, exercise and laser therapy.

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

Guideline Based on Canadian Research

Interestingly, the guideline for American doctors is based on reviews of over 200 clinical studies by Canadian researchers at McMaster University in Ontario, who developed Canada’s opioid prescribing guideline. The Canadian guideline, which recommends against the use of opioids as a first-line treatment, is modeled after the CDC’s controversial 2016 opioid guideline.  

After reviewing data from over 13 million U.S. insurance claims, McMaster researchers estimated the risk of prolonged opioid use after a prescription for acute pain was 27% for “high risk” patients and 6% for the general population.

"Opioids are frequently prescribed for acute musculoskeletal injuries and may result in long-term use and consequent harms," said John Riva, a doctor of chiropractic and assistant clinical professor in the Department of Family Medicine at McMaster. "Potentially important targets to reduce rates of persistent opioid use are avoiding prescribing opioids for these types of injuries to patients with past or current substance use disorder and, when prescribed, restricting duration to seven days or less and to lower doses."

Riva and his colleagues said patients are also at higher risk of long-term use if they have a history of sleep disorders, suicide attempts or self-injury, lower socioeconomic status, higher household income, rural residency, lower education level, disability, being injured in a motor vehicle accident, and being a Medicaid recipient.

A history of alcohol abuse, psychosis, episodic mood disorders, obesity, and not working full-time “were consistently not associated with prolonged opioid use.”

The McMaster research, also published in the Annals of Internal Medicine, was funded by the National Safety Council (NSC), a non-profit advocacy group in the U.S. supported by major corporations and insurers. The NSC has long argued against the use of opioid pain relievers, saying they “do not kill pain, they kill people.”

Wear, Tear & Care: Rating the Pain Creams

By Jennifer Kain Kilgore, Columnist

I am a connoisseur of pain creams. My idea of Christmas is when my friend’s mom mailed me a box filled with unopened packages of Bengay (true story). Every morning I slather on a layer of something containing menthol in order to numb my back. Then my cat decides to attack me. Why? Because cats love menthol (also a true story).

Anyway, I have tried many, many, many different topical anesthetics over the years. Here are my experiences with the common and unique brands:

Bengay: The gold standard. Whenever I use this brand, I generally gravitate toward the pain relief massage gel. However, my friend’s mom sent me the regular Bengay.

What, you thought I was kidding? Here’s a picture of my Bengay drawer.

There’s no doubt about it: Bengay is good. However, even the massage gel only contains 2.5 percent menthol, which is the active ingredient that transports your skin to the Arctic. It also has camphor, like what’s used in Vick’s VapoRub, to reduce pain and swelling.

While Bengay is good, it’s not great. Moving on!

Cryoderm has been my go-to for years, because it is, as they claim, “as cold as ice.” It has 10 percent menthol and also contains arnica and boswellia, the former of which has been used for centuries to control bruises and swelling. The latter is a solid anti-inflammatory agent. Cryoderm also makes a number of heat-producing products, one of which I own.

I use it on very cold winter days when the temperature makes me want to crawl back into bed. If I put it on during the rest of the year, I prematurely begin the process of menopause.

Anyway, just because I am a big fan of Cryoderm does not mean I haven’t tried other things, such as…

Emu oil: Last year I was at the Big E (only the greatest annual fair in the northeast, where all food is deep fried, even the Kool Aid) when, naturally, I gravitated toward a booth that was hawking pain relief products. They all centered around emus. Yes, that flightless bird from Australia. Apparently its oil can be used for anything, from cracked heels to unsightly patches on your skin. I used it for pain purposes, and I found it to be lacking. Not only was it difficult to apply, but it was ineffective. My search continued.

Arnica cream: This took the inactive ingredient in Cryoderm and went whole-hog by making it the active ingredient -- nay, the only ingredient. I think this would do a bang-up job of healing something acute, like bruises immediately following an injury. But for chronic, long-term pain, I was left wanting.

Lidocaine patches are available by prescription only, though there are some almost-as-powerful creams and patches online. I only get 10 at a time because they normally are not covered by my insurance.

These things are fantastic. If I could wrap myself in one like a big numb burrito, I would.

It contains 700 mg of lidocaine, which, based on the word’s suffix, you might recognize as a numbing agent similar to novocaine.

You can slap one on for 12 hours at a time; however, like any other sticky product, it can irritate the skin. These are perfect for very bad days, but what’s the next best thing if you can’t get your insurance to cover them?

Stopain. I have to admit, I was skeptical when my grandmother suggested this. Here is a close transcript our conversation:

“Honey, I saw this thing on TV that works on bad backs. You gotta get it.”

For reference, my grandmother is a Jew from Brooklyn in her upper eighties. She wears tracksuits with heels, always has makeup on, and has the best white Jewfro you could possibly imagine. Since friends and relatives are always suggesting pain relief products (which I do appreciate), I didn’t put much stock in what she said.

“Grandma, you can’t always believe that ‘As seen on TV’ stuff.'"

I didn’t actually say “stuff.” I said another word that starts with “S.”

“You watch your mouth with me, kiddo. Give it a try. C’mon, do it for me. The commercial said it really worked!”

So I bought it to humor her and let it sit in its packaging for about a week once it arrived. Then, when I ran low on my Cryoderm bottle, I gave it a whirl. I was prepared for it not to work, since the Cryoderm has 10 percent menthol and Stopain only has 8 percent, but... I was incredibly surprised.

I’ve been using it for a few weeks now, and I think it actually works better than the Cryoderm despite having less menthol. What it lacks in that ingredient, it makes up for in boswellia, arnica, eucalyptus oil, peppermint oil, and other things I can’t pronounce. It’s a veritable cornucopia of pain-relieving ointments.

So there you have it. Hopefully my experiences have saved you some time, and if not, at least you will smell delightful to any feline companions.

J. W. Kain is an attorney in the Greater Boston area who also works as a writer and editor in her spare time.  She has chronic back and neck pain after two car accidents.

You can read more about J.W. on her blog, Wear, Tear, & Care.  

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.