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PAIN CONTROL
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Uses and Dosing

NSAIDs: There is no evidence to suggest one NSAID is better than another for pain control. Lower doses have pain-relieving effects and treat fever, while higher doses have anti-inflammatory effects. They are used for pain control, inflammation, arthritis and fever. Examples of over-the counter NSAIDs include naproxen and ibuprofen. Examples of prescription NSAIDs include: meloxicam, diclofenac, celecoxib, along with naproxen and ibuprofen. Specific dosing varies depending on the NSAIDs being used. Be sure to discuss appropriate dosing with your physician.

Acetaminophen: This is the most common medication for pain relief related to mild to moderate osteoarthritis. Acetaminophen is a good option for medically complex patients. It is used for temporary relief of headaches, fever, and muscle and joint pains. The recommended maximum daily dose is 3,000 mg/day.

Corticosteroids: This type of medication is prescribed for episodes of inflammation caused by specific problems, such as arthritis. Sports medicine physicians commonly inject corticosteroids, or prescribe it for oral use. Examples include prednisone, methylprednisolone, and triamcinolone. Specific dosing varies depending on the steroid medication being used. Be sure to discuss appropriate dosing with your physician.

Narcotics: Also known as opiate pain medications. Used for severe pain (i.e. acute trauma and fractures). These should only be prescribed when other medications are not effective or are contraindicated. When used, they should only be taken for a short period of time due to the risk of dependence. These medications should be started at a low dose to monitor effects. Examples include hydrocodone and oxycodone. Specific dosing varies depending on the medication being used. Be sure to discuss appropriate dosing with your physician.

 

How They Work

NSAIDs: Block enzymes responsible for pain and inflammation.

Acetaminophen: Not completely understood. Pain relieving effects may be related to alterations of neurotransmitters in the central nervous system. Acetaminophen acts on the temperature controlling area of the brain to treat fever.

Corticosteroids: Affects cell metabolism to lessen inflammation.

Narcotics: Act on the brain and nervous system to lessen the perception of pain.

 

Side Effects and Warnings

More information can be found at: www.FDA.gov/Drugs/

NSAIDs: Risk of cardiovascular events, i.e. heart attack and stroke, for all people. People with a history of heart disease have a higher risk. Kidney problems, gastrointestinal ulcers, headache, rash, nausea and vomiting are also possible. Although risk appears to be greater with higher doses and longer duration, there is no safe dose or duration. People allergic to NSAIDs, children recovering from a viral illness, and people at risk for ulcers should not take NSAIDs. Pregnant women should discuss with their physician prior to using NSAIDs.

Acetaminophen: Long-term, daily use may increase risk of liver damage. People with chronic alcoholism, severe liver disease, or an allergy to acetaminophen should not take acetaminophen. Certain medications, like those used to prevent seizures, may make side-effects more likely. Less gastrointestinal side-effects than NSAIDs.

Corticosteroids: If injected, can cause loss of coloration (fading of the skin) and thinning of the skin. Injection into a tendon can lead to injury (possibly tendon rupture). High blood pressure or blood sugar is possible, but often temporary. Changes in mood or thinking, muscle or bone injury, and other problems are possible.

Narcotics: Risk of overdose, especially with high doses, longer duration, or when used with other medicines/substances, i.e. alcohol and benzodiazepines. Risk of dependence, addiction, or allergic reaction. Risk of serotonin syndrome when taken with certain medications used to treat mental illness/depression. Risk of toxicity if used with acetaminophen (many narcotic medications have a small amount of acetaminophen in them).

 

Injury Prevention

NSAIDs & Acetaminophen: Not used to prevent injury, but can be used with caution prior to activity to lessen minor, sport-related soreness.

Corticosteroids: Not used to prevent injury, but helpful for specific problems.

Narcotics: Not used prior to performance because of side effects that might increase risk of injury (i.e. drowsiness).

 

Duration of Treatment

NSAIDs: Preferably short-term (i.e. two weeks).

Acetaminophen: As long as needed for pain, but use long-term with caution.

Corticosteroid: Joint and other injections are typically limited to four per year. Used short-term if taken by mouth (i.e. five-seven days). If topical, used short-term (i.e. two weeks).

Narcotics: Used short-term (i.e. a few days), until severe pain is controlled and other treatment is provided.

AMSSM Member Authors
Rathna Nuti, MD and Blake Corcoran, MD

References
Bhala N, Emberson J, Merhl A, Abramson S, Arber N. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analysis of individual participant data from randomized trials. Coxib and traditional NSAID Trialistsí (CNT) Collaboration. Lancet. 2013; 382: 369-379.
FDA. FDA Drug Safety Communication: FDA strengthens warning that nonaspirin nonsteroidal anti-inflammatory drugs (NSAIDs) can cause heart attacks or strokes. https://www.fda.gov/Drugs/DrugSafety/ucm451800.htm. Published July 9, 2015.
Harrast M, Finnoff J. Sports Medicine: Study Guide and Review for Boards. Demos Medical Publishing; 2011.
Sachs CJ. Oral analgesics for acute nonspecific pain. American Family Physician. 2005;1: 913-918.
Schjerning Olsen A, Fosbol E, Lindhardsen J. Duration of treatment with nonsteroidal anti-inflammatory drugs and impact on risk of death and recurrent myocardial infarction in patients with prior myocardial infarction: a nationwide cohort study. Circulation. 2011; 123: 2226-2235.

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