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Management for Musculoskeletal Pain Disorders

Musculoskeletal pain, both complex and perplexing, affects every person in the world at some time or other. Next, to the common cold, pain is the reason patients seek a healthcare practitioner. One of the most prevalent, challenging, and influential problems facing modern society is chronic pain. Statistics related to the incidence of pain are amazing but do not tell the entire story, as many of those affected are family, friends, and employers of those experiencing the pain. While most individuals experience acute, mild to moderate pain, some individuals experience chronic, severe musculoskeletal pain. The number of patients living with chronic musculoskeletal pain is expected to increase with the aging population and with the rise in obesity and diabetes across the nation.  While it is true that patients do not die from benign pain, many patients suffer needlessly and experience a disabling and pleasureless existence. It substantially impacts a patient’s psychological, social, vocational, behavioral, and physical well- being. Some severely afflicted chronic musculoskeletal pain patients sadly do not look forward to a long life; rather, they anxiously await an end to their suffering. The impact of unrelieved chronic musculoskeletal pain can result in a decreased quality of life, functionality, activity, appetite, productivity, earned wages, and a willingness to be compliant with medical therapy.  It can also increase patient/ family financial burden, hospital costs, the number and duration of hospitalizations, pain, and suffering, and suicidal tendencies if the pain becomes intolerable.  Musculoskeletal pain affects the bones, muscles, ligaments, tendons, and nerves and can be acute or chronic. Anyone can experience musculoskeletal pain. It is most often caused by an injury to the bones, joints, muscles, tendons, ligaments, or nerves. Musculoskeletal pain can be either localized or widespread. Lower back pain is possibly the most common type of musculoskeletal pain; some of the other more common types of musculoskeletal pain are listed in Table 1 and various causes of musculoskeletal pain in  Table 2.

Symptoms

Symptoms of musculoskeletal pain depend on whether the pain is caused by an injury or overuse and whether it is chronic or acute. The symptoms can also differ from person to person. Patients with musculoskeletal pain sometimes complain that their entire body aches, their muscles may feel that they have been pulled or overworked, and sometimes the patient’s muscles may twitch or burn. Even though symptoms vary from person to person, the common symptoms are listed in Table 3.

 

Table 1. Types of Pain.
Bone pain Usually deep, penetrating, or dull. It most commonly results from injury. It is important to be sure that the pain is not related to a fracture or tumor.
Muscle pain Often less intense than bone pain, but it can still be debilitating. Muscle pain can be caused by an injury, an autoimmune reaction, loss of blood flow to the muscle, infection, or a tumor. The pain can also include muscle spasms and cramps.
Tendon and ligament pain Often caused by injuries, including include sprains. This type of musculoskeletal pain often becomes worse when the affected area is stretched or moved.
Fibromyalgia A condition that may cause pain in the muscles, tendons, or ligaments. The pain is usually in multiple locations and can be difficult to describe. Fibromyalgia is usually accompanied by other symptoms.
Joint pain Joint injuries and diseases usually produce a stiff, aching, “arthritic” pain. The pain may range from mild to severe and worsens when moving the joint. The joints may also swell. Joint inflammation (arthritis) is a common cause of pain.
“Tunnel” syndromes Refer to musculoskeletal disorders that cause pain due to nerve compression; includes carpal tunnel syndrome, cubital tunnel syndrome, and tarsal tunnel syndrome. The pain tends to spread along the path supplied by the nerve and may feel like burning. These disorders are often caused by overuse

Musculoskeletal pain is best treated by treating its cause; this varies depending on whether the patient is experiencing bone, muscle, ligament, tendon, or joint pain, or some other kind of musculoskeletal pain.  Musculoskeletal pain can be treated by different approaches; Tables 4 and 5 list those approaches and also provide the typical drugs that can be used. Table 6 contains various dosage forms that are either manufactured or compounded.  Fibromyalgia patients can be prescribed medications to increase the body’s level of serotonin and norepinephrine (neurotransmitters that modulate sleep, pain, and immune system function), which may be prescribed in low doses.

Patient-Specific compounded medications

Over the last 10 years, the number of prescriptions that have been compounded for pain therapy has dramatically increased. A significant portion of these compounded analgesic preparations are made up of topical/transdermal dosage forms such as gels and creams.

The advantages of topical/transdermal formulations include:

  1. Bypassing first-pass metabolism
  2. Lower systemic toxicity
  3. Ease of use and overall better patient compliance

One of the most intriguing aspects of these formulations is the local versus systemic effects. It appears that many of these drugs are acting to inhibit pain locally, allowing physicians to reduce dosing and reduce systemic side effects.

Some examples of compounded pain medications are shown in Table 7, but almost any combination of a drug from Table 5 and dosage form from Table 6 can be put together for individual patients by your local compounding pharmacist.

 

Table 5. Analgesics.

Opioid Analgesics

Alfentanil, Codeine, Fentanyl, Hydrocodone, Hydromorphone, Levorphanol, Meperidine, Methadone, Morphine, Oxycodone, Oxymorphone, Remifentanil, Sufentanil, Tapentadol, Tramadol.

Opioid Agonist-Antagonist Analgesics

Buprenorphine, Butorphanol, Nalbuphine, Pentazocine

Central Analgesics

Clonidine

Salicylates

Aspirin, Diflunisal, Magnesium salicylate, Methylsalicylate Salsalate

Nonsteroidal Anti-inflammatory Agents

Celecoxib Diclofenac, Etodolac, Fenoprofen, Flurbiprofen, Ibuprofen, Indomethacin, Ketoprofen, Ketorolac, Meclofenamate, Mefenamic acid, Meloxicam, Nabumetone, Naproxen, Oxaprozin, Piroxicam, Sulindac, Tolmetin

Other

Acetaminophen, Capsaicin

Table 7. Compounded Formulations for Pain Management.

Solutions:

Dexamethasone and Lidocaine Solution for Iontophoresis Morphine Sulfate 10-mg/mL Inhalation Solution Meperidine Hydrochloride 10 mg/5 mL and Promethazine

Hydrochloride 10 mg/5 mL in Cherry Syrup

Transdermal/Topical gels:

Ibuprofen 20% and Piroxicam 2% in Transdermal Base

Capsaicin and Ketorolac in Pluronic Lecithin Organogel

Cyclobenzaprine Hydrochloride 0.5% and Naproxen 10% in Transdermal Base

Topical creams:

Hydrocortisone 10% Cream for Phonophoresis

Medication sticks:

Analgesic Medication Stick with Capsaicin

Troches:

Morphine Sulfate 15-mg Troche (#24, 1 g troches)

Buprenorphine 0.1-mg Troches (#24, 1 g troches)

Capsules:

Morphine Sulfate 15-mg and Dextromethorphan Hydrobromide 30-mg Capsules

Codeine Phosphate 32.5-mg, APAP 325-mg, and Phenyltoloxamine Citrate 30-mg Capsules

Intrathecal Solutions:

Morphine Sulfate 30-mg/mL Intrathecal Solution

Bupivacaine Hydrochloride 1.25-mg/mL and Fentanyl Citrate 20-mcg/mL Injection for Ambulatory Pump Reservoir

TAbLe 2. Causes of Pain.

  • Wear and tear
  • Trauma
  • Auto accidents
  • Falls
  • Fractures
  • Sprains
  • Dislocations
  • Direct blows
  • Postural strain
  • Repetitive movements
  • Overuse
  • Prolonged immobilization
  • Postural changes
  • Poor body mechanics and others

Table 3. Common Symptoms of Pain.

  • Localized or widespread pain that may or may not worsen with movement
  • Aching or stiffness of the entire body
  • The feeling that your muscles have been pulled or overworked
  • Fatigue
  • Sleep disturbances
  • Twitching muscles
  • The sensation of “burning” in your muscles

Table 4. Approaches to Treating Pain.

  • Physical or occupational therapy, manual therapy
  • Mobilization/immobilization
  • Medications
  • Strengthening/conditioning stretching exercises
  • Heat/cold
  • Acupuncture or acupressure
  • Relaxation/biofeedback techniques
  • Osteopathic manipulation
  • Chiropractic care
  • Therapeutic massage

Loyd V. Allen, Jr., Ph.D., RPh Editor-in-Chief

International Journal of Pharmaceutical Compounding

Remington: The Science and Practice of Pharmacy, Twenty-second Edition

Summary
Pain Management for Musculoskeletal Disorders
Article Name
Pain Management for Musculoskeletal Disorders
Description
Pain, both complex and perplexing, affects every person in the world at some time or other. Next, to the common cold, pain is the reason patients seek a healthcare practitioner. One of the most prevalent, challenging, and influential problems facing modern society is chronic pain.
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