Treatments for Acute Pain: A Systematic Review

Abstract

Objectives. To evaluate the effectiveness and comparative effectiveness of opioid, nonopioid pharmacologic, and nonpharmacologic therapy in patients with specific types of acute pain, including effects on pain, function, quality of life, adverse events, and long-term use of opioids. Data sources. Electronic databases (Ovid® MEDLINE®, PsycINFO®, Embase®, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews) to August 2020, reference lists, and a Federal Register notice. Review methods. Using predefined criteria and dual review, we selected randomized controlled trials (RCTs) of outpatient therapies for eight acute pain conditions: low back pain, neck pain, other musculoskeletal pain, neuropathic pain, postoperative pain following discharge, dental pain (surgical or nonsurgical), pain due to kidney stones, and pain due to sickle cell disease. Meta-analyses were conducted on pharmacologic therapy for dental pain and kidney stone pain, and likelihood of repeat or rescue medication use and adverse events. The magnitude of effects was classified as small, moderate, or large using previously defined criteria, and strength of evidence was assessed. Results. One hundred eighty-three RCTs on the comparative effectiveness of therapies for acute pain were included. Opioid therapy was probably less effective than nonsteroidal anti-inflammatory drugs (NSAIDs) for surgical dental pain and kidney stones, and might be similarly effective as NSAIDs for low back pain. Opioids and NSAIDs were more effective than acetaminophen for surgical dental pain, but opioids were less effective than acetaminophen for kidney stone pain. For postoperative pain, opioids were associated with increased likelihood of repeat or rescue analgesic use, but effects on pain intensity were inconsistent. Being prescribed an opioid for acute low back pain or postoperative pain was associated with increased likelihood of use of opioids at long-term followup versus not being prescribed, based on observational studies. Heat therapy was probably effective for acute low back pain, spinal manipulation might be effective for acute back pain with radiculopathy, acupressure might be effective for acute musculoskeletal pain, an opioid might be effective for acute neuropathic pain, massage might be effective for some types of postoperative pain, and a cervical collar or exercise might be effective for acute neck pain with radiculopathy. Most studies had methodological limitations. Effect sizes were primarily small to moderate for pain, the most commonly evaluated outcome. Opioids were associated with increased risk of short-term adverse events versus NSAIDs or acetaminophen, including any adverse event, nausea, dizziness, and somnolence. Serious adverse events were uncommon for all interventions, but studies were not designed to assess risk of overdose, opioid use disorder, or long-term harms. Evidence on how benefits or harms varied in subgroups was lacking. Conclusions. Opioid therapy was associated with decreased or similar effectiveness as an NSAID for some acute pain conditions, but with increased risk of short-term adverse events. Evidence on nonpharmacological therapies was limited, but heat therapy, spinal manipulation, massage, acupuncture, acupressure, a cervical collar, and exercise were effective for specific acute pain conditions. Research is needed to determine the comparative effectiveness of therapies for sickle cell pain, acute neuropathic pain, neck pain, and management of postoperative pain following discharge; effects of therapies for acute pain on non-pain outcomes; effects of therapies on long-term outcomes, including long-term opioid use; and how benefits and harms of therapies vary in subgroups.

Is otologic surgery contributing to the opioid epidemic?

“…The authors also stated that there might be a sufficient effect by NSAID or α-agonists monotherapy, as well as through nerve blocks [ 15 ], however, further studies assessing non-opioid use for pain control after otologic surgery is needed. Similar or even superior pain control of NSAIDs compared to opioids such as hydrocodone have been shown for various other surgical procedures such as rhinoplasties [ 16 ] or for acute pain in general, including postoperative pain [ 17 ].…”

“…Nevertheless, we believe that this questionnaire based analysis provides important aspects and insights to possibilities of non-opioid therapy for postoperative pain. As mentioned above, in several other surgical fields sufficient postoperative pain control with NSAIDs comparable or even superior to opioids has been shown in randomized studies and meta-analyses [ 16 , 17 , 24 , 25 ]. Primarily, treatment of pain following otologic surgery should therefore be attempted without opioids.…”

A systematic review of chiropractic care for fall prevention: rationale, state of the evidence, and recommendations for future research

“…A substantiative body of research has evaluated the potential for multimodal chiropractic care to reduce or manage musculoskeletal pain. Recent systematic reviews and meta-analyses have concluded that SM as a part of multimodal chiropractic care has favorable outcomes on pain severity in patients with chronic LBP [82,83] and acute LBP with radiculopathy [84]. Additional reviews also support that SM can be a beneficial component of treatment plans for reducing the severity of both neck [85,86] and LBP [87,88].…”

Terapia Manual no tratamento da dor: uma revisão integrativa

“…Com o propósito de modular a dor e aumentar a amplitude de movimento, segundo a Academia de Terapia Manual Americana publicada pela IFOMPT (Federação Internacional de Fisioterapeutas Ortopédicos Manipulativos)². Dor é uma experiência sensitiva e emocional desagradável associada, ou semelhante àquela associada, a uma lesão tecidual real ou potencial 3 . A dor é quase universal, contribuindo substancialmente para a morbidade, mortalidade, incapacidade e sobrecarga do sistema de saúde 4 .…”