Counsel Patients on OTC Analgesics

Patients commonly self-treat pain with nonprescription analgesics, and pharmacists can help them choose the correct OTC products.

Acute pain typically initiates abruptly and can often be attributed to a known cause such as an injury or surgery.¹ Chronic pain typically lasts for 3 or more months and can be caused by a condition, disease, inflammation, an injury, medical treatment, or an unknown reason.¹

Pain is a complex symptom that affects individuals differently, and therapy should be tailored to the individual’s needs. Left untreated, pain may affect quality of life, including cognitive, emotional, and physical functions.

Because of the opioid crisis in the United States, many health care professionals are exploring alternative approaches to pain relief, such as cognitive therapy, cold and heat treatments, physical therapy, and OTC oral and topical analgesics.¹

Many individuals frequently use nonprescription oral and topical analgesics to self-treat mild to moderate pain because the products are accessible, easy to use, and reasonably priced. Consumers spent $4.5 billion on oral analgesics and $1.1 billion on topical analgesics in 2020, according to a Consumer Healthcare Products Association report.²

Selecting an appropriate nonprescription product may be overwhelming for many patients, especially if they have other medical conditions and/or are taking other medications. Therefore, pharmacists are in a critical position to advise patients on oral and topical nonprescription analgesics, as well as direct them to seek counsel from their primary health care providers when warranted. That is especially important if further evaluation is needed, the pain is severe, or self-treatment is not appropriate.

Recommendations and Recent News

The American Academy of Family Physicians and the American College of Physicians (ACP) in August 2020 recommended the use of topical nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy for treating acute, non–low back pain from musculoskeletal injuries in outpatient settings.³ Evidence has shown that topical NSAIDs are among the most effective options for pain reduction, physical function, symptom relief, and treatment satisfaction, and they have not been linked with any considerable adverse effects. The ACP guidelines suggest other treatment options when appropriate, including oral NSAIDs to diminish or relieve symptoms and acupressure and transcutaneous electrical nerve stimulation to decrease pain.³

“These types of injuries and associated pain are common, and [as physicians] we need to address them with the best treatments available for the patient,” Jacqueline W. Fincher, MD, MACP, president of the ACP, said. “The evidence shows that there are quality treatments available for pain caused by acute musculoskeletal injuries that do not include the use of opioids. There are a number of recommended interventions that are not opioids to choose from, and topical NSAIDs should be the first line of treatment.”³

The results of a study published in European Journal of Pain indicated that pain has been frequently described as a clinical feature of COVID-19, and the main pain syndromes that have been linked with the acute phase of the virus are arthritis, headaches, myalgia, and neuropathic pain.⁴

The results of a study published in Nature Reviews Endocrinology issued a consensus statement cautioning against the use of nonprescription acetaminophen during pregnancy. The authors warned of possible links to adverse fetal development outcomes, called for additional investigation, and encouraged additional precautions prior to use in pregnancy.⁵

However, some experts have indicated that more research is warranted and that the findings from the study should not change clinical decision-making.⁶

In response to the publication, medical societies including the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine have made statements continuing to encourage the safe administration of acetaminophen to patients who need it during pregnancy.⁶

National Health Interview Survey data published in Pain stated that 50.2 million, or 20.5%, of adults in the United States in 2019 experienced chronic pain.⁷ The estimated total value of lost productivity due to chronic pain is nearly $300 billion annually.⁷

Conclusion

Pharmacists should advise patients about the proper use of the selected product, including adherence to manufacturer directions, dosage, potential adverse effects, and recommended duration of use. Pharmacists also serve as excellent resources in identifying possible drug-drug contraindications and interactions. Patients taking other medications and those with chronic medical conditions should always consult their primary health care providers before taking any nonprescription drugs. Pharmacists can also make recommendations about using nonpharmacological measures to alleviate joint and muscle pain.

For example, the RICE protocol (rest, ice, compression, elevation) helps diminish inflammation and swelling associated with acute joint and muscle injuries, and localized heat therapy may be beneficial for patients with noninflammatory pain.

Encourage patients with continual, severe, or recurring pain to seek additional care from their primary health care providers, especially if pain worsens or they see no signs of progress after using nonprescription analgesics. Advise patients to limit the use of systemic analgesics to 10 days unless otherwise directed by their primary health care providers.

Yvette C. Terrie, BSPHARM, RPH, is a consulting pharmacist and a medical writer in Haymarket, Virginia.

References

1. Safely and effectively managing pain without opioids. CDC. June 11, 2021. Accessed October 14, 2021. https://www.cdc.gov/drugoverdose/ featured-topics/pain-management.html

2. OTC use statistics. Consumer Healthcare Products Association. Accessed October 28, 2021. https://www.chpa.org/about-consum- er-healthcare/research-data/otc-use-statistics

3. ACP, AAFP release new guideline for treatment of non-low back pain from musculoskeletal injuries in adults. American College of Physicians. August 17, 2020. Accessed October 14, 2021. https://www. acponline.org/acp-newsroom/acp-aafp-release-new-guideline-for- treatment-of-non-low-back-pain-from-musculoskeletal-injuries-in

4. Oguz-Akarsu E, Gullu G, Kilic E, et al. Insight into pain syndromes in acute phase of mild-to-moderate COVID-19: frequency, clinical characteristics, and associated factors. Eur J Pain. Published online October 8, 2021. doi:10.1002/ejp.1876

5. Bauer AZ, Swan SH, Kriebel D, et al. Paracetamol use during pregnancy - a call for precautionary action. Nat Rev Endocrinol. Published online September 23, 2021. doi:10.1038/s41574-021-00553-7

6. D’Ambrosio A. Warning on Tylenol in pregnancy no cause for alarm. MedPage Today. October 11, 2021. Accessed October 12, 2021.https:// www.medpagetoday.com/obgyn/pregnancy/94967

7. Yong RJ, Mullins PM, Bhattacharyya N. Prevalence of chronic pain among adults in the United States. Pain. Published online April 2, 2021. doi:10.1097/j.pain.0000000000002291