What are the medications for chronic Musculoskeletal (MSK) pain?

From the Guidelines

For chronic musculoskeletal pain, a stepped approach starting with acetaminophen (500-1000mg every 6 hours, maximum 4g daily) or NSAIDs like ibuprofen (400-800mg three times daily with food) or naproxen (250-500mg twice daily) is recommended. This approach is based on the strongest and most recent evidence, which suggests that acetaminophen and NSAIDs are effective and safe for the treatment of musculoskeletal pain 1.

Key Considerations

• Acetaminophen has fewer side effects than NSAIDs, but lower dosing is recommended for patients with liver disease 1.
• NSAIDs, such as ibuprofen and naproxen, are effective for musculoskeletal pain, but their use is limited to patients not at risk for coronary artery disease 1.
• Topical options like diclofenac gel or lidocaine patches can provide localized relief with fewer systemic side effects.
• Adjunct medications including duloxetine or gabapentin may help with neuropathic components of pain.

Non-Pharmacological Approaches

• Physical therapy, heat/cold therapy, and gentle exercise should accompany medication to target different pain mechanisms while minimizing side effects.
• Regular reassessment is essential to evaluate effectiveness and adjust treatment as needed, with the goal of improving function while using the lowest effective medication dose.

Additional Options

• Muscle relaxants such as cyclobenzaprine may be considered for short-term use in patients with musculoskeletal pain 1.
• Anticonvulsants like gabapentin and pregabalin are considered first-line treatments for neuropathic pain, but their use is limited by side effects such as somnolence, dizziness, and weight gain 1.

From the FDA Drug Label

Naproxen has been studied in patients with rheumatoid arthritis, osteoarthritis, juvenile arthritis, ankylosing spondylitis, tendonitis and bursitis, and acute gout. Improvement in patients treated for rheumatoid arthritis was demonstrated by a reduction in joint swelling, a reduction in duration of morning stiffness, a reduction in disease activity as assessed by both the investigator and patient, and by increased mobility as demonstrated by a reduction in walking time. In patients with osteoarthritis, the therapeutic action of naproxen has been shown by a reduction in joint pain or tenderness, an increase in range of motion in knee joints, increased mobility as demonstrated by a reduction in walking time, and improvement in capacity to perform activities of daily living impaired by the disease.

Naproxen can be used for the treatment of chronic musculoskeletal (MSK) pain associated with conditions such as osteoarthritis and rheumatoid arthritis.

• The medication has been shown to reduce joint pain and tenderness, and improve mobility and range of motion in patients with these conditions.
• However, it is essential to use naproxen with caution and under the guidance of a healthcare provider, as it can cause adverse effects such as gastrointestinal events and nervous system effects 2.
• Patients should be closely monitored for side effects, and the medication should be used at the lowest effective dose for the shortest duration necessary 2.

From the Research

Medication for Chronic MSK Pain

• The management of chronic musculoskeletal (MSK) pain is a complex condition that requires a multidisciplinary approach, including pharmacological, non-pharmacological, and interventional pain therapy 3.
• Recent guidelines recommend the implementation of preventative strategies and physical tools first to minimize the use of medications 3.
• Non-pharmacologic, noninvasive treatment approaches, such as exercise, cognitive behavior therapy, and mindfulness techniques, can yield small to moderate improvement in chronic MSK pain 4.
• Medications, including analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), and narcotics, can be used to control pain, but their use requires careful selection and consideration of potential toxicities, especially in the elderly 5.
• The use of oral medication in the treatment of chronic MSK pain in the elderly requires careful selection of drugs to control pain with consideration for both the physiological state and the presence of disease(s) 5.

Non-Pharmacological Interventions

• Multimodal analgesia and multidisciplinary approaches are fundamental elements of effective management of MSK pain 3.
• Non-pharmacological interventions, such as physical exercise, patient education, and complementary approaches, can be effective in managing chronic MSK pain 6.
• Cognitive behavior therapy and mindfulness techniques appear to be effective for small to moderate short- and long-term improvement of chronic low back pain 4.
• Spinal manipulation, acupuncture, and massage or myofascial release can also provide small to moderate benefits for chronic MSK pain 4.

Pharmacological Interventions

• Analgesics, including NSAIDs and narcotics, can be used to control pain, but their use requires careful selection and consideration of potential toxicities 5.
• Anti-inflammatory agents, such as prednisolone and triamcinolone, can be used to control cytokine production and reduce pain 5.
• Antidepressants and anticonvulsants may be of value in some patients with chronic MSK pain, but more knowledge is needed to give general recommendations 7.