OTC Case Studies: Back Pain

CASE 1: Nonpharmacological Therapy

Q: MP is a 54-year-old woman who has worked as an office manager at a desk all day for 25 years and who has a sedentary lifestyle. She also commutes 30 minutes each way to her office. MP does not engage in physical activity other than short evening walks after dinner when weather permits. MP helped her adult son move into a new home the day prior and lifted boxes and furniture. That caused lower back pain, and she thinks she may have strained her muscles. MP inquires about rest, ice, compression, and elevation (RICE) as a nonpharmacological approach to managing the back pain. What should the pharmacist advise?

A: Although acute back pain may be self-limiting, a nonpharmacological approach with RICE may help decrease the inflammation associated with muscle injury and promote recovery. The RICE method is best applied in the first 72 hours of injury and may be applied with or without pharmacological interventions.^1,2

It is recommended that MP rest her back for 24 to 48 hours to promote healing. She should refrain from weight-bearing activities during this time. Encourage MP to apply ice to her back for 15 minutes 3 to 4 times daily for 24 to 72 hours. Compression can be applied to the back using an elastic bandage or wrap. To prevent future back pain due to bursts of activity, MP should aim for moderate physical activity and stretch to strengthen muscles.^1,2

CASE 2: Osteoarthritis

Q: JR is picking up acetaminophen for pain relief for his wife, MR,
a 66-year-old woman with osteoarthritis. She has been experiencing lower back pain due to osteoarthritis of the hips. JR says that MR does not have a significant medical history apart from the osteoarthritis. She has been taking acetaminophen for many years, but it has not relieved her back pain. JR asks about other nonprescription relief for back pain resulting from osteoarthritis of the hip. What should the pharmacist recommend?

A: In previous years, acetaminophen was recommended as a first-line analgesic for arthritic pain relief instead of nonsteroidal anti-inflammatory drugs (NSAIDs) in relieving pain. In recent years, evidence-based guidelines have steered away from acetaminophen and changed the first-line recommendation for osteoarthritic pain. The 2019 American College of Rheumatology/ Arthritis Foundation (ACR/AF) guidelines, for example, strongly recommend oral NSAIDs as first-line agents for this patient population. Similarly, the Osteoarthritis Research Society International (OARSI) 2019 guidelines removed oral acetaminophen for all forms of osteoarthritis. The caution taken in recommending NSAIDs as first-line pain relief is understandable, given the risk of serious adverse effects (AEs) such as cardiac events, gastrointestinal (GI) bleeding and ulcers, and nephropathy. Despite the risks, the ACR/AF and OARSI guidelines considered the benefits versus risks and recommended the use of NSAIDs first. Furthermore, the OARSI guidelines recommend the addition of a proton pump inhibitor to lessen the risk of GI ulcerations in cases where a patient is at high risk for AEs and if nonselective NSAIDs will be used continuously. Like the ACR/AF and OARSI guidelines, American College of Physicians guidelines on treatment of all chronic back pain recommend oral NSAIDs first rather than oral acetaminophen for pharmacological treatment.^1,3-5

Given the absence of significant risk of GI bleeding for MR and the data available, the pharmacist should recommend that she switch to NSAIDs for back pain relief.

CASE 3: Topical Anesthetics

Q: PM is a 27-year-old woman who calls the pharmacy for advice on treating lower back pain due a recent sprain from a new workout class. She has tried acetaminophen, oral NSAIDs, and RICE therapy. PM does not want to continue taking systemic medications. She says she felt some relief when using 1 of her mother’s leftover prescription-strength Lidoderm patches. PM asks whether a similar OTC product is available. What information can the pharmacist provide?

A: PM has tried the first-line recommendations for acute back pain: oral NSAIDs and RICE. Like the prescription-strength transdermal patch, lidocaine is available over the counter, as is topical lidocaine, as a cream, gel, lotion, and ointment. The maximum OTC strength of lidocaine is 4%.⁶

Remind PM that topical lidocaine should not be applied more than 3 times daily for a maximum of a week. The absorption of lidocaine will increase with exercise, heat application, and skin moisture. PM should wash her hands after each application and avoid contact with mucous membranes. She should avoid applying lidocaine to areas with skin injury and discontinue if irritation occurs and clean the skin. If PM starts using the OTC patch, she can wear it on clean, dry skin for up to 8 hours.⁶

CASE 4: Heat

Q: EP is a 57-year-old woman with lower back pain and a history of osteoarthritis. She calls the pharmacy with questions regarding her back pain and stiffness. EP reports that she tried the RICE method last week after acute pain onset and has not yet felt relief. She has heard that heat may also be a potential intervention for this type of pain. What information can the pharmacist provide to EP regarding heat therapy for back pain?

A: For acute back pain
and stiffness that is not inflammatory in nature, thermotherapy may deliver relief. Unlike ice therapy, heat should not be applied when inflammation is present, as the heat could perpetuate vascular leakage and vasodilation. The ACR/AF guidelines also recommend thermotherapy as a nonpharmacological treatment for osteoarthritic pain. Applying heat can decrease muscle spasms, increase blood flow to the affected area, and relieve stiffness. Different forms of heat applications studied include heating pads, hot-water bottles, and warm compresses. Newer products include heat-generating pads and wraps.^3,4,7

Apply the heat for 15-minute periods 3 to 4 times daily. Overall, heat therapy should not be applied on areas of broken skin or recent injury, as this may increase the risk of skin burn. Ready-to-use heat wraps can be applied to the back for a maximum of 8 to 12 hours, depending on the product label. The adhesives should be applied to clean, dry skin. EP should avoid using lotions or topical analgesics underneath the heat application, as this may also increase the risk of skin burns. If she experiences burning, itching, or pain upon application of heat, she should remove the heat immediately.^4,7

Rupal Patel Mansukhani, PharmD, FAPhA, NCTTP, is a clinical associate professor at Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, in Piscataway, and a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.

Ammie J. Patel, PharmD, BCPS, BCACP, is a clinical assistant professor
of pharmacy practice and administration at Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, in Piscataway, and an ambulatory care specialist at RWJBarnabas Health Primary Care in Shrewsbury and Eatontown, New Jersey.

REFERENCES

1. Qaseem A, Wilt T, McLean R, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. doi:10.7326/M16-2367
2. Sprains and strains. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Updated January 2015. Accessed October 17, 2021. https://www.niams.nih.gov/health-topics/sprains-and-strains
3. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2020;72(2):149-162. doi:10.1002/acr.24131
4. Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019;27(11):1578-1589. doi:10.1016/j.joca.2019.06.011
5. Osteoarthritis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. October 2019. Accessed October 31, 2021. https://www.niams.nih.gov/health-topics/osteoarthritis
6. External analgesic drug products for over-the-counter human use: tentative final monograph. FDA. Fed Regist. 1983;48(27):5852. Accessed October 18, 2021. http://cdn.loc.gov/service/ll/fedreg/fr048/fr048027/fr048027.pdf#page=138
7. Nelson AE, Allen KD, Golightly YM, Goode AP, Jordan JM. A systematic review of recommendations and guidelines for the management of osteoarthritis: the Chronic Osteoarthritis Management Initiative of the U.S. Bone and Joint Initiative. Semin Arthritis Rheum. 2014;43(6):701-712.