1. Analgesics for musculoskeletal pain
Sydney
Broome
Fremantle

2. EJ Visser Churack Chair UNDA 2018 copyright
Pain
Nociceptive pain
Neuropathic pain
Due to a lesion or disease of the somatosensory nervous system
Nociplastic pain
Sensitization (amplification)
Modulation
Allodynia
EJ Visser Churack Chair UNDA 2018 copyright

3. EJ Visser Churack Chair UNDA 2018 copyright
Aims of analgesia
Pharmacotherapy: part of a multimodal pain Mx approach
Acute pain relief
acute to chronic pain transition
functional rehabilitation (physiotherapy)
risk of adverse effects
chemical coping, addiction
Mx chronic pain
EJ Visser Churack Chair UNDA 2018 copyright

4. Lets review the drug cupboard

5. Paracetamol Not sure how paracetamol works? Maximum 8 per day
COX-2, ‘cannabinoid’, serotonin?
Maximum 8 per day
Mainstay analgesic in most pain protocols
No good for acute or chronic pain (Cochrane)
individual responders
older patients
Combination paracetamol analgesics are more effective

6. Analgesia league table
NNT
Celecoxib
Ibuprofen
Paracetamol ibuprofen
Paracetamol tramadol
Panadeine forte 60/
Paracetamol
Oxycodone 5 mg
Tramadol 100mg
Codeine 60mg

7. NSAIDs & coxibs NSAIDS: ibuprofen, aspirin
COXIBS: celecoxib (COX-2 selective)
Anti-inflammatories
Prostaglandin synthesis (COX)
Good prostaglandins (housekeeping)
Renal & gastric risk
Cardiovascular risk
Bleeding risk
Gut
Airway
Kidney
Bone healing
Vessels Platelets
Tissue healing

8. NSAIDs & coxibs Celecoxib Ibuprofen, naproxen, diclofenac
Effective for acute pain (NNT <3)
≤7 days
Not for chronic pain
Rapid-acting formulations ARE better
Side effects (belly, bladder, bleeding)

9. Analgesia league table
NNT
Celecoxib
Ibuprofen
Paracetamol ibuprofen
Paracetamol tramadol
Panadeine forte 60/
Paracetamol
Oxycodone 5 mg
Tramadol 100mg
Codeine 60mg

10. Tramadol Opioid, noradrenaline, serotonin Acute pain
Neuropathic pain (NNT 4)
↓ Respiratory depression & constipation
↓ Addiction (S4)
Ineffective in 10% (prodrug, 2D6 enzyme)
Renal accumulation, seizures, interactions, serotonin
Serotonin
Noradrenaline
Opioids

11. Analgesia league table
NNT
Celecoxib
Ibuprofen
Paracetamol ibuprofen
Paracetamol tramadol
Panadeine forte 60/
Paracetamol
Oxycodone
Tramadol
Codeine

12. Tapentadol (Palexia) ‘Weak’ opioid (S8) & noradrenaline analgesic
Similar to tramadol without serotonin
↓ Side effects
Acute pain
Neuropathic pain
Chronic pain

13. Opioids for chronic pain
Poor risk vs benefit
Don’t work well (NNT = 8, NNH = 4) (Level I)
Risk of adverse effects
classical side effects, tolerance, hyperalgesia, overuse, addiction
Contraindicated in non specific spinal pain, fibromyalgia
OK to trial in >60s with spondylosis or OA joint pain
3Ts: tramadol SR, tapentadol SR, transdermal buprenorphine
Ceiling dose is ≤ 60 mg oral morphine equivalents/day

14. Combination analgesics
For acute pain only
Paracetamol 500 mg/ ibuprofen 200 mg (OTC)
Paracetamol 325 mg/ tramadol 37.5 mg (Zaldiar) (script)
Paracetamol 500 mg/ codeine 30 mg (script)
Ibuprofen 200 mg/ codeine 12 mg (Nurofen plus) (script)

15. Analgesia league table
NNT
Celecoxib
Ibuprofen
Paracetamol ibuprofen
Paracetamol tramadol
Panadeine forte 60/
Paracetamol
Oxycodone
Tramadol
Codeine

16. Antidepressants & anticonvulsants
NOT effective for nociceptive pain
Duloxetine (SNRI) is moderately effective (noradrenaline effect)
Chronic LBP & knee pain
Neuropathic pain (NNT 4)
Pregabalin, gabapentin
Not effective for LBP
Radicular leg pain?

17. Other analgesics Topical NSAIDs
OA knee, hands, enthesopathy, tendonopathy
Topical capsaicin cream
OA knee, hands
Menthol 4% gel

18. EJ Visser Churack Chair UNDA 2017 copyright
Steroids
Oral (prednisolone)
Acute inflammatory arthritis, tendonitis, enthesitis, myositis
Early CRPS?
Acute radiculopathy?
Injection
Radicular leg pain (transforaminal epidural)
Knee, hip, shoulder, facet, SIJ, soft tissues
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19. EJ Visser Churack Chair UNDA 2017 copyright
Distal limb injuries
Vitamin C 1000 mg/d for 4 weeks  CRPS O2 free radical scavenger  neurogenic inflammation
EJ Visser Churack Chair UNDA 2017 copyright

20. EJ Visser Churack Chair UNDA 2017 copyright
Sleep & supplements
Sleep
Melatonin, valerian, lavender
Amitriptyline, pregabalin
Anti-inflammatories
Curcumin
PEA (lecithin nutraceutical)
Chondroitin & glucosamine
EJ Visser Churack Chair UNDA 2017 copyright

21. EJ Visser Churack Chair UNDA 2017 copyright
Cutting edge?
Neuroimmune & glial modulators
Fibromyalgia, CFS, CRPS
Melatonin
Minocycline (antibiotic)
Metformin (diabetes)
Naltrexone
EJ Visser Churack Chair UNDA 2017 copyright

22. EJ Visser Churack Chair UNDA 2017 copyright
Controversies
Codeine
Cannabinoids
Benefits < risks
NNT 15 for both
Individual responders?
Muscle spasms
Orphenadrine or baclofen (diazepam*) for muscle spasms
EJ Visser Churack Chair UNDA 2017 copyright

23. Acute musculoskeletal pain
Comfort measures (heat)
Combination paracetamol/ibuprofen prn (≤ 4 days)
Severe…
Celecoxib mg bd (≤ 7 days)
Combination paracetamol/tramadol or codeine prn OR…
IR tapentadol or oxycodone prn
≤ 4/24 prn, ≤ 4 x daily, ≤ 4 days

24. Acute severe radicular pain
Neuropathic pain (nociceptive, muscle spasms)
Analgesics are poorly effective (level I)
Tramadol, tapentadol or oxycodone
Pregabalin
Steroids (transforaminal injection or oral)
Natural history; improvement in 3-6 months

25. Thank you