Jason Busse, DC, PhD, on Pain Management for Acute Musculoskeletal Injuries

Opioids are not more effective, but are more harmful, than alternatives when treating acute, non-low-back musculoskeletal injuries, according to the results of 2 new evidence reviews.1,2 The findings show that other treatments, such as a combination of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen are just as effective and have less risk of harms to patients than opioids.

The first of 2 systematic reviews and meta-analyses1 focused on prolonged use of opioids in patients treated for acute musculoskeletal injuries such as sprains and strains. Using data from 14 studies that included 13,263,393 participants, the researchers found that the prevalence of prolonged opioid use within the general population was 6%. However, the prevalence for high-risk populations, including patients receiving Workers’ Compensation benefits, Veterans affair claims, and patients with substance abuse disorders, was 27%.

The second review2 included 207 studies that enrolled 33,000 participants. The researchers evaluated 45 different therapies as alternative treatments for opioids for sprains, strains, whiplash, nonsurgical fractures, and contusions.

Consultant360 spoke with Jason Busse, DC, PhD, who was the lead investigator on these studies and is an associate professor in the Department of Anesthesia and of Health Research Methods, Evidence and Impact at McMaster University, about the findings and their implications.


Consultant360: What was your reasoning for focusing specifically on opioid use with sprains and strains, and not other injuries?

Jason Busse: The scope of our review was informed by the National Safety Council and the American College of Physicians (ACP) to support a clinical practice guideline. The focus of the guideline was management of acute pain due to out-patient musculoskeletal injuries. We were asked to exclude low back injuries, as the ACP published a guideline on management of these injuries in 2017.3

CON360: What is the current standard-of-care for treating acute, non-low-back musculoskeletal injuries?

JB: Standard-of-care is highly variable and often includes prescription opioids at substantial doses. An analysis of 30,832 opioid-naïve US patients who received treatment for acute ankle sprains from 2011 to 2015 showed a median opioid-prescribing rate of 25%, with a median morphine equivalent dose of 100 mg/d.

CONC360: Your review suggests that topical NSAIDs, followed by oral NSAIDs, and then acetaminophen showed the most convincing benefit-to-harm ratio for patients with acute pain from non-low-back musculoskeletal injuries. How do you suppose these results will affect the current treatment landscape for these and similar injuries?

JB: Our review, which evaluated 45 different therapeutic approaches for acute pain from non-low-back musculoskeletal injuries, should help standardize management. Specifically, reduce use of opioids for these injuries, encourage use of topical NSAIDs when feasible, and use of oral NSAIDs or acetaminophen when not.

CON360: How could your findings impact the current opioid epidemic?

JB: The opioid epidemic is complex and influenced by prescription opioids, diversion, and illicit opioids. Our findings provide reassurance that patients presenting with acute pain from non-low-back musculoskeletal injuries can achieve similar relief to opioids from nonopioid therapy (eg, NSAIDs), with less risk of harms.

These results, if applied to clinical practice, should reduce the use of opioids for acute musculoskeletal pain. Fewer patients prescribed opioids for acute pain should reduce the proportion who transition to chronic opioid use and decrease the opportunity for prescription opioids to be diverted.

Well-designed observational studies will be needed to confirm a shift in prescribing practices and, more important, if such changes (if present) are associated with improved outcomes for patients, including a reduction in opioid-related harms (eg, addiction, overdose, death).

CON360: What knowledge gaps for treating these types of injuries would you wish to be addressed in future studies?

JB: Our review identified a number of treatment options for acute pain from non-low-back musculoskeletal injuries that are promising but are currently supported by only low- to very-low-certainty evidence; specifically, transcutaneous electrical nerve stimulation, joint manipulation, and specific acupressure. Also, as a result of limiting our search to English-language articles, we did not find trials that explored the effectiveness of acupuncture.

Future reviews would benefit from including non-English studies, and future trials should explore potentially promising nonpharmacologic therapies for acute pain from non-low-back musculoskeletal injuries to inform their role.



  1. Riva JJ, Noor ST, Wang L, et al. Predictors of prolonged opioid use after initial prescription for acute musculoskeletal injuries in adults: a systematic review and meta-analysis of observational studies. Published online August 18, 2020. Ann Intern Med. doi:10.7326/M19-3600
  2. Busse JW, Sadeghirad B, Oparin Y, et al. Management of acute pain from non-low back musculoskeletal injuries: a systematic review and network meta-analysis of randomized trials. Published online August 18, 2020. Ann Intern Med. doi:10.7326/M19-3601
  3. Qaseem A, Wilt TJ, McLean, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Published online April 4, 2017. Ann Intern Med.