_________________________________________________________________________ Neck Pain in Adults
In some cases, it is not the study design but the paradigm itself that limits usefulness. Randomized controlled trials have evaluated analgesic efficacy in patients with specific pathologies (e.g., disk herniation, degenerative processes). The efficacy of oral analgesics is mostly unrelated to underlying tissue pathology, which can produce diverse pain mechanisms. Pain mechanism targeting is now emphasized [69; 70]. Central sensitization is recognized to underlie many chronic neck pain cases and is very difficult to treat. Optimized pain reduction can require combining medications that target peripheral inputs in the dorsal horn (bottom-up) and descending pain modulation pathways (top-down) with tapentadol (opioid and norepinephrine reuptake inhibitor) or opioids plus NSAIDs, norepinephrine reuptake inhibitors, or anticonvulsants. Adding topical analgesics can help decrease peripheral nociceptive input [69; 96; 121; 122]. A 2017 practice guideline recommended combining analgesics in chronic pain treatment [123]. Assessment of Analgesic Response Assessing treatment response to neck pain pharmacotherapy is very important. This requires the patient reaching and maintaining adherence to a target dose at which therapeutic effect is expected for at least two weeks. The most common errors are underdosing and insufficient treatment duration [71]. Assess treatment response using a 0–10 scale, and use the results to help guide treatment planning [71]. With a pain reduction to <3, continue monotherapy and consider indication for combination therapy, when appropriate. For a pain reduction by ≥30% but a pain intensity ≥4, combine the existing therapy with an additional first-line drug. If pain is reduced by <30% and the pain intensity ≥4, the drug should be considered ineffective and the patient should be switched to another first-line agent. It is also important to check for side effects [71]. If intolerable side effects prevent effective dosing, switch to another drug. If the patient is taking a clinically effective dose but intolerable side effects continue, lower the dose before switching analgesics. Depending on the therapeutic and side effects after this is done, try switching the drug or starting combination therapy with a low dose of the original drug. If the pain relief remains inadequate, consult a pain specialist or refer the patient to a pain center. Acetaminophen Acetaminophen (paracetamol) is a nonsalicylate antipyretic analgesic recommended as first-line therapy in mild-to-moderate acute or chronic low back, spinal, and musculoskeletal pain [124; 125; 126]. Enduring assumptions of its efficacy and safety were first challenged by a randomized controlled trial of 1,649 patients with acute low back pain. Following 28 days of acetaminophen or placebo taken as regular dosing (three times per day) or as needed for pain, acetaminophen did not differ
from placebo on any pain outcome, average time to recovery, or tablets consumed per day [125]. Reviews of placebo-controlled trials concluded that acetaminophen was ineffective in reducing pain and disability in low back pain and showed little evidence of efficacy in diverse chronic pain conditions. Even 4,000 mg/day for 1 to 12 weeks had no effect beyond placebo on pain, quality of life, function, or sleep quality in acute low back pain, and any effect in chronic low back pain was uncertain [124; 126; 127]. A caveat is that very few studies have evaluated acetaminophen in neck pain. Acetaminophen shows a significant dose-response effect for increased risks of cardiovascular, renal, and GI adverse effects, suggesting considerable toxicity risk, especially at the upper end of standard analgesic dosing [128]. Acetaminophen may cause liver failure in acute overdose or chronic excessive exposure [129]. The universal endorsement and routine use of acetaminophen as first-choice analgesic in acute and chronic neck pain is questioned [124; 125; 126]. Muscle Relaxants Appropriate for muscle spasm with pain, there is strong evidence that muscle relaxants can provide short-term pain relief in acute low back pain (and by extension, neck pain due to spasm). Clinicians should consider the side effects of drowsiness or dizziness. Carisoprodol is not recommended because its active metabolite, meprobamate, is a drug with abuse potential [103]. NSAIDs NSAIDs are endorsed universally as first-line therapy for acute mild-to-moderate pain of any origin and broadly as first-line therapy for diverse chronic pain conditions, including neck pain. NSAIDs have similar pharmacology but diverse molecular structure. Patient response to specific NSAIDs varies, and several trials of different NSAIDs may be needed to identify an effective agent [103]. A meta-analysis evaluated 35 randomized controlled trials for NSAID efficacy in low back, neck, and sciatica pain. Pain and disability outcomes of NSAIDs or placebo were pooled and averaged, and differences were compared using a 0–10 scale. No study reported outcomes beyond 12 weeks. Only two neck pain studies were found, and the outcomes of these studies were for less than four weeks [130]. NSAIDs surpassed placebo in neck pain reduction by 1.6, a minimally important difference to patients in pain. NSAIDs surpassed placebo by 1.2 in disability reduction. Average differences between NSAIDs and placebo in low back pain/ sciatica were lower than neck pain. In aggregate, six participants required treatment with NSAIDs, instead of placebo, for one additional participant to achieve clinically important pain reduction [130].
49
MDKY1626
Powered by FlippingBook