Ask the Pharmacist

Q) So, my twenty year olds wound up having to spend the summer with us instead of in the big city doing twenty year old type things. All good, of course, but in my excitement at having them home, I attempted to keep them entertained and be involved in their lives by participating in a number of sporting activities with them to a greater degree than perhaps my less than supple body could manage. What are you now recommending for all my aches and strains?

A) Ahh, this just might be a question that I asked myself as I sit here on my lap top with an icepack on my shoulder and a TENS machine working on my left knee which is currently about the same size as my noggin. It’s all just another casualty of the great Canadian staycation of the summer of 2020. And, just in time (for me at least..) new guidance on just this issue was released jointly by the American College of Physicians and the American Academy of Family Physicians.

These are both well established and respected institutions whose advice can be trusted and should form the basis for treatment decisions by both you and me as well as by our physicians.

Some of the recommendations should not come as a surprise to anyone but they have made major changes in at least two suggestions that might provide possible answers for some of our weekend warriors who have failed to improve using traditional therapies.

Anyone who has been following the news for the last few years will hardly fall over in shock to read that the experts feel there is no real reason to use the opioids (otherwise known as  narcotics and including drugs such as codeine, tramadol and, of course, morphine and Oxycocet) in any musculoskeletal injuries except in cases of a severe injury or if all of the other first-line therapies have failed to provide enough of a benefit.

In general, the research pretty clearly shows that the opioids provide little benefit in this treatment area and are associated with substantial harms such as addiction, dependence, potential for overdose as well as sedation leaving patients vulnerable to vehicle and other types of accidents. This all makes sense to me, it is just a shame it took us so many years to recognize what should have been fairly clear long ago.

The other suggestion that matches what most would have expected is that our traditional pain killers such as acetaminophen (Tylenol) and the NSAID’s (non-steroidal anti-inflammatories) such as ibuprofen (Advil), naproxen (Aleve), celecoxib (Celebrex) and many others remain go-to options. Acetaminophen has the advantage in that just about anyone can safely take it but has a couple of drawbacks as well when compared to the NSAID’s.

First, it does not get rid of inflammation which is frequently a problem after a recent injury to a muscle or connective tissue such as a ligament or tendon. Secondly, it tends to last for a shorter period of time which is inconvenient and can impact sleep if it wears off and the pain awakens you. Acetaminophen does use the liver to metabolize in the body so anyone with liver issues may need to avoid its use.

The challenges with using the NSAID’s is that they fairly commonly can bother one’s stomach and there are a lot of people who either should not take them or, if they do so, are increasing their risk of suffering an adverse health outcome. Thus, NSAID’s should either not be used or used with caution in people with kidney problems, a current or past history of ulcers, people with poorly controlled high blood pressure, people with asthma, people with heart disease and people on certain medications such as diuretics (or water pills as they are sometimes referred to) or blood thinners. There is also some controversy at this point as to whether the use of NSAID’s can impair the healing process of bone, ligament, tendon and muscle injuries. Expect to read more about this in the coming years. It should be noted that if increased pain relief is required, acetaminophen can be safely taken simultaneously with an NSAID.

Now, as far as the new strategies for treatment went, there was one category that emerged as a clear winner. That was the use of topical (i.e. creams and ointments) NSAID’s which was the only treatment choice that improved all outcomes (the outcomes being tracked was achievement of pain relief within 2 hours and then again at 1 & 7 days, physical function, symptom relief, treatment satisfaction and adverse drug side effects). This was based on their exhaustive review of over 207 trials involving more than 32,000 people.

There is currently only one NSAID topical available without a prescription (Voltaren in 2 different strengths) but many pharmacies regularly compound prescription requiring creams that are 5 to 10 times more potent than Voltaren and are equally well tolerated. These NSAID creams can also be modified, if need be, to provide even greater symptom relief via the addition of extra ingredients such as the cooling effects of menthol or the nerve blocking or muscle relaxing abilities of chemicals such as baclofen and amitriptyline. For patients looking to try an option such as this, contact your pharmacist who can guide you as to what might work best for you and can contact your physician to discuss this as a possible solution to your injury.

The other major new intervention was the suggestion that acupuncture either alone or in combination with transcutaneous electrical nerve stimulation (i.e. a TENS machine) can be a very effective side effect free treatment for these types of injuries.

For an “older” adult who graduated all the way back in 1990, it’s a bit of a shock to see official acknowledgement of non traditional therapies that were regarded with great skepticism by practitioners of western medicine. TENS machines in particular are wonderful in that they have come way down in price and can be done in the comfort of your home as you read or watch the Raptors finish off the Celtics on the tv.

For many, the best results will come from combining therapies such as taking a pill of acetaminophen while rubbing an NSIAD cream on a sore shoulder and periodically strapping on a couple of TENS pads. Also, it should be noted that the application of heat and or ice, the use of a splint or brace, reducing workload or resting the afflicted area, learning to reduce stress through biofeedback techniques and making use of other health professionals such as a physiotherapist, chiropractor or massage therapist can all aid and speed your recovery. For more information about this or any other health related questions, contact your pharmacist.