Pain is the main reason Americans access the health care system, according to the National Institutes of Health.1 Pharmacists, as the most accessible health care providers,2 should know about and recommend the most effective pain management.

Opioids are often prescribers’ go-to for pain management. Originally extracted from the poppy plant, opioids are known as powerful painkillers.3 But scientific evidence proves otherwise, according to the National Safety Council and a Cochrane review. Opioids relieve mild to moderate pain but have been proven less effective than OTC ibuprofen for most types of pain, with the exception of cancer, discussed below.3

The issues clinicians see with opioids are their adverse effects (AEs), including addiction, confusion, constipation, dependence, dry mouth, drowsiness, nausea, tolerance, and vomiting.4 But research indicates that opioids are more effective for psychotherapeutic effects, such as anxiety and depression, than for pain.5

Pharmacists’ recommendations for pain management should be both effective and safe, which describes OTC medications, including acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). Common NSAID classes include acetic acids (diclofenac, indomethacin, and ketorolac), COX-2 inhibitors (celecoxib), propionic acids (ibuprofen, ketoprofen, and naproxen), and salicylates (aspirin).3 Study results show that the combination of acetaminophen and ibuprofen is more effective in treating pain’s associated emotional distress than opioids.3

Safety is always a concern. NSAIDs’ common AEs include gastrointestinal (GI) irritation, GI ulcers, and negative effects on renal function.3 Because it is neither an NSAID nor an opioid, acetaminophen avoids many AEs. However, it does carry a risk of liver toxicity.

To prove efficacy scientifically, many researchers have evaluated the number needed to treat (NNT), comparing several analgesics (table 1).6-8 NNT is the number of people who must be treated with a chosen intervention for 1 person to receive the desired effect.3 For this reason, a lower NNT is desirable, as this would signify a more potent medication.



Selecting the best treatment for each patient can be challenging. To do so accurately, pharmacists must first consider patient-specific issues that may affect medication selection (table 2).3



RECOMMENDATIONS FOR ACUTE PAIN
Pain treatment is fraught with myth and uncertainty (table 3). For back pain, specifically sciatica, researchers found that opioids were ineffective.9 For dental pain, researchers found that the best recommendation is 325 mg of acetaminophen and 200 mg of ibuprofen daily after tooth extraction.10 And for severe pain, researchers found that NSAIDs and opioids were both effective.11



RECOMMENDATIONS FOR CHRONIC PAIN
Opioids are found to be beneficial in the short term but are ineffective in the treatment of chronic pain, which is defined as pain lasting longer than 4 months.12

Recommendations for chronic pain include nonpharmacologic and pharmacologic treatment. Nonpharmacologic treatments include acupuncture, cognitive behavioral therapy, exercise therapy, peer support, and weight loss.13 When nonpharmacologic therapy is insufficient to improve pain, consider nonopioid pharmacologic therapies, such as acetaminophen, anticonvulsants, antidepressants, and NSAIDs.11 The general recommendation is, if and when opioids are used, prescribers should also prescribe nonopioids and nonpharmacologic therapy.14

Cancer pain is a specific subset of chronic pain and has unique recommendations. For mild cancer pain, the recommendation is acetaminophen and NSAIDs. Opioids are used for more severe pain or when acetaminophen and NSAIDs are no longer effective. This is the only time that opioids are effective in cancer. Regarding end-of-life pain, opioids are not used to treat the pain but instead to relieve anxiety and treat depressions acutely.12
 
Monique F. Miller is a PharmD candidate at the University of Connecticut in Storrs.

REFERENCES
  1. US Department of Health and Human Services. Pain management. National Institutes of Health website. report.nih.gov/nihfactsheets/ViewFactSheet.aspx?c-sid=57. Accessed June 17, 2019.
  2. Tsuyuki RT, Beahm NP, Okada H, Al Hamarneh YN. Pharmacists as accessible primary health care providers: Review of the evidence. Can Pharm J (Ott). 2018;151(1):4-5. doi: 10.1177/1715163517745517.
  3. Teater D. Evidence for the efficacy of pain medications. National Safety Council website. sdcms.org/Portals/18/Assets/Lev%20Docs/Evidence-Efficacy-Pain-Medications.pdf. Accessed June 22, 2019.
  4. Corli O, Santucci C, Corsi N, Radrezza S, Galli F, Bosetti C. The Burden of opioid adverse events and the influence on cancer patients’ symptomatology. J Pain Symptom Manage. 2019:57(5):899-908.e6. doi: 10.1016/j.jpainsymman.2019.02.009.
  5. Tenore PL. Psychotherapeutic benefits of opioid agonist therapy. J Addict Dis. 2008;27(3):49-65. doi: 10.1080/10550880802122646.
  6. Gaskell H, Derry S, Moore RA, McQuay HJ. Single dose oral oxycodone and oxycodone plus paracetamol (acetaminophen) for acute postoperative pain in adults. Cochrane Database Syst Rev. 2009;(3):CD002763. doi: 10.1002/14651858. CD002763.pub2.
  7. Derry C, Derry S, Moore RA, McQuay HJ. Single dose oral naproxen and naprox- en sodium for acute postoperative pain in adults. Cochrane Database Syst Rev. 2009;(1):CD004234. doi: 10.1002/14651858.CD004234.pub3.
  8. Derry CJ, Derry S, Moore RA. Single dose oral ibuprofen plus paracetamol (acetaminophen) for acute postoperative pain. Cochrane Database Syst Rev. 2013;(6):CD010210. doi: 10.1002/14651858.CD010210.pub2.
  9. Lewis RA, Williams NH, Sutton AJ, et al. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. Spine J. 2015;15(6):1461-77. doi: 10.1016/j.spinee.2013.08.049.
  10. Moore PA. Hersh EV. Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions: translating clinical research to dental prac- tice. J Am Dent Assoc. 2013;144(8):898-908.
  11. Holdgate A. Pollock T. Nonsteroidal anti-inflammatory drugs (NSAIDs) ver- sus opioids for acute renal colic. Cochrane Database Syst Rev. 2004;(1):CD004137.
  12. Holle LM. Rational opioid use: continuous learning after the CDC Guideline. University of Connecticut School of Pharmacy Continuing Education website. ce. pharmacy.uconn.edu/wp-content/uploads/sites/2102/2019/03/CDC-Guideline- MAR2019-FINAL.pdf. Accessed June 22, 2019.
  13. Medina R, Sorrell T, Techau A, Weiss J. Treating chronic pain and opioid misuse disorder among underserved populations in Colorado [published online May 30, 2019]. J Am Assoc Nurse Pract. doi:10.1097/JXX.0000000000000238.
  14. Dowell D, Haegerich TM, Chou R. CDC Guideline for prescribing opioids for chronic pain – United States, 2016. MMWR Recomm Rep. 2016;65(1):1-49. doi: 10.15585/mmwr.rr6501e1.