The guidelines established by the New York State Workers Compensation Board are designed to assist healthcare professionals in prescribing medications for Neck Injuries. These directives aim to support physicians and healthcare practitioners in determining the appropriate pharmaceutical interventions for individuals with neck injuries.
Healthcare professionals specializing in Neck Injuries can rely on the guidance provided by the Workers Compensation Board to make well-informed decisions about the most suitable medications for their patients.
It is important to stress that these guidelines are not meant to replace clinical judgment or professional expertise. The ultimate decision regarding medication for neck injuries should involve collaboration between the patient and their healthcare provider.
Medication for Neck Injury
For the initial choice of medication, it’s commonly suggested for most individuals to go for ibuprofen, naproxen, or other NSAIDs from the older generation. If NSAIDs aren’t suitable, acetaminophen (or its counterpart paracetamol) could be a reasonable alternative, although it’s worth noting that evidence leans towards NSAIDs being slightly more effective. Importantly, research indicates that NSAIDs provide pain relief comparable to opioids (including tramadol) but with less associated impairment.
Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic Neck Pain
For the management of acute, subacute, or chronic neck pain, it is recommended to use NSAIDs. Over-the-counter (OTC) options may be sufficient and are advised as the first attempt. The frequency and duration of use can be tailored to individual needs and may be reasonable for many patients. Reasons to discontinue use include the resolution of symptoms, lack of effectiveness, or the emergence of adverse effects necessitating discontinuation.
NSAIDs for Patients at High Risk of Gastrointestinal Bleeding
It is recommended to consider the concomitant use of cytoprotective drugs, such as misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors, for patients at a high risk of gastrointestinal bleeding. This is particularly crucial for patients with a high-risk factor profile who also require NSAIDs, especially when considering longer-term treatment. High-risk patients encompass those with a history of prior gastrointestinal bleeding, the elderly, diabetics, and cigarette smokers.
Regarding frequency, dose, and duration, proton pump inhibitors, misoprostol, sucralfate, and H2 blockers are recommended, and their dosage and frequency should align with the manufacturer’s guidelines. There is generally no substantial difference in efficacy among these medications for preventing gastrointestinal bleeding. Reasons for discontinuation include intolerance, the development of adverse effects, or discontinuation of NSAIDs.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
Patients with known cardiovascular disease or multiple risk factors for cardiovascular issues should engage in a discussion about the risks and benefits associated with NSAID therapy for pain. It is recommended that, as the first line of therapy, acetaminophen or aspirin be considered as they appear to pose the least risk regarding cardiovascular adverse effects. If NSAIDs are deemed necessary, non-selective ones are preferred over COX-2 specific drugs.
For patients taking low-dose aspirin for primary or secondary cardiovascular disease prevention, precautions should be taken to minimize the potential for the NSAID to counteract the beneficial effects of aspirin. Specifically, the NSAID should be taken at least 30 minutes after or eight hours before the daily aspirin.
Acetaminophen for Treatment of Neck Pain
It is recommended to use acetaminophen for the treatment of neck pain, especially in patients with contraindications for NSAIDs. This recommendation applies to all patients experiencing neck pain, whether it’s acute, subacute, chronic, or post-operative. The dosage and frequency should align with the manufacturer’s recommendations, and it can be used on an as-needed basis. It’s important to note that exceeding four grams per day may lead to hepatic toxicity. Reasons for discontinuation include the resolution of pain, the occurrence of adverse effects, or intolerance.
Topical Medications
It is recommended to consider topical creams, ointments, and lidocaine patches for select patients experiencing pain associated with acute, subacute, or chronic neck pain. The rationale behind this recommendation lies in the potential benefits of topical drug delivery, including capsaicin, topical lidocaine, topical NSAIDs, and topical salicylates and nonsalicylates. This approach may be suitable for specific patients, provided strict instructions for application and the maximum number of daily applications are followed to achieve the desired benefit and avoid potential toxicity. However, the effects of long-term use are largely unknown, and therefore, episodic use may be more prudent for most patients.
Capsaicin is noted as a safe and effective alternative to systemic NSAIDs, with its use limited by a local stinging or burning sensation that tends to diminish with regular application. Users should be instructed to apply the cream using a plastic glove or cotton applicator to prevent inadvertent contact with eyes and mucous membranes, and long-term use of capsaicin is discouraged.
Topical lidocaine is specifically recommended when there is documented neuropathic pain, and a trial period of no greater than four weeks is suggested. Additional use should be contingent on documented functional gains.
Topical NSAIDs, such as diclofenac gel, may achieve potentially therapeutic tissue levels with low systemic absorption, making them advantageous in situations where systemic administration is relatively contraindicated.
Topical salicylates or nonsalicylates, like methyl salicylate, do not appear to be more effective than topical NSAIDs overall. They may be considered for short-term use, especially in patients with chronic conditions for whom systemic medication is relatively contraindicated, or as an adjunct to systemic medication.
Opioids
It is not recommended to use opioids for acute, subacute, or chronic neck pain. However, it is recommended for limited use, not exceeding seven days, for postoperative pain management as adjunctive therapy to more effective treatments. This prescription of opioids is often required, particularly at night, as an adjunct to more efficacious treatments such as NSAIDs and acetaminophen.
The frequency and duration should be based on a prescribed as-needed basis throughout the day initially, then later only at night, before gradually weaning off completely. The rationale for this recommendation is that some patients may experience insufficient pain relief with NSAIDs, and judicious use of opioids may be helpful, especially for nocturnal use. Opioids are advised for brief and selective use in postoperative patients, primarily at night, to facilitate sleep after surgery.
Anti-Depressants
Tricyclic anti-depressants (TCAs)
It is recommended to consider tricyclic antidepressants (TCAs) for non-acute neck pain that is not fully treated with NSAIDs and an exercise program, especially in cases where there is nocturnal sleep disruption and mild dysthymia.
The typical approach involves prescribing a very low dose at night, gradually increasing (e.g., amitriptyline 25 mg at bedtime, increased by 25 mg each week) until a submaximal or maximal dose is achieved, sufficient effects are obtained, or adverse effects occur. Most practitioners prefer lower doses (e.g., amitriptyline 25-75 mg/day) to avoid adverse effects and the need for blood level monitoring, as higher doses do not show increased pain relief. Imipramine, being less sedating, may be a better option if there is daytime sedation carryover.
Discontinuation is recommended upon resolution of pain, intolerance, or the development of adverse effects. It is worth noting that there is limited evidence that tricyclic antidepressants (TCAs) lead to modest reductions in pain ratings in the treatment of radicular pain compared with a placebo.
Selective Serotonin Reuptake Inhibitors (e.g., paroxetine, as well as bupropion and trazodone)
It is not recommended to use anti-depressants for the treatment of non-acute neck pain. Even though they may be recommended for the treatment of depression, there is strong evidence suggesting that these medications do not provide benefits for managing non-acute neck pain without depression. Additionally, there is no quality evidence supporting the efficacy of anti-depressants in the treatment of acute neck pain. Therefore, in the absence of other indicators necessitating such treatment, using anti-depressants is not recommended for managing acute neck pain.
Anti-Seizure Drugs
Topiramate
It is recommended to consider the use of gabapentin in select patients with non-acute neck pain, especially when multiple other modalities have failed, including trials of different NSAIDs, aerobic exercise, specific stretching exercise, strengthening exercise, tricyclic antidepressants, distractants, and manipulation.
The typical approach involves initiating the medication by gradually increasing the dose. Patients should be carefully monitored for the development of adverse events. Discontinuation is advised upon resolution of symptoms or the development of adverse effects. Due to elevated risks for central nervous system (CNS) sedating adverse effects, careful monitoring is particularly important for employed patients.
However, it is not recommended for neuropathic pain, including peripheral neuropathy.
Carbamazepine
It is recommended to consider the use of carbamazepine as a potential adjunct for non-acute radicular or neuropathic pain after attempting other treatments, such as other medications, aerobic exercise, and manipulation. While there is not high-quality evidence for the treatment of non-acute radicular neck pain, carbamazepine may be tried if other medications have proven ineffective.
The frequency and duration of use are based on the prescribed medication. Discontinuation is advised upon the resolution of neck pain, lack of efficacy, or the development of side effects that necessitate discontinuation. Careful monitoring of employed patients is essential due to elevated risks for central nervous system (CNS) sedating adverse effects.
Gabapentin and Pregabalin
It is advisable to use duloxetine for the peri-operative management of pain to reduce the need for opioids, particularly in individuals experiencing side effects from opioids. Additionally, duloxetine is recommended for select patients dealing with severe neurogenic claudication from spinal stenosis or chronic radicular pain syndromes with limited walking distance.
However, duloxetine is not recommended for axial or non-neuropathic pain. Discontinuation is recommended upon resolution of the issue or if intolerance occurs. Careful monitoring of employed patients is essential due to elevated risks for central nervous system (CNS)-sedating adverse effects.
Compound Medications
Not Recommended – Topical, oral and/or systemic compound medications
Skeletal Muscle Relaxants
Muscle relaxants, excluding carisoprodol, are suggested as a secondary option for specific cases involving moderate to severe acute neck pain. Typically, these agents may not be necessary, as other medications, progressive walking, and exercises are often sufficient to manage symptoms. Prescribing these agents initially at night, especially on non-workdays or when patients don’t plan to drive, is recommended. Caution is advised when prescribing to individuals with a history of depression, personality disorders, or substance addiction, including alcohol or tobacco.
If needed for such patients, cyclobenzaprine is preferred due to its resemblance to tricyclic antidepressants, with lower risk of addiction or abuse. The initial dose should be taken in the evening, and daytime use is acceptable if minimal CNS-sedating effects are observed. Higher doses beyond the effective range are not recommended. If significant daytime somnolence occurs, discontinuation may be necessary, especially if it hinders participation in aerobic exercise and other rehabilitation components. Taking the first dose before starting work or operating machinery is discouraged. Discontinuation is recommended upon pain resolution, intolerance, significant daytime sedation, or the occurrence of other adverse effects.
Recommended as second or third-line options for moderate to severe radicular pain syndromes or post-surgical pain believed to be musculoskeletal. Other agents might offer better efficacy for relieving radicular pain. Typically, they are used for one week, with a maximum duration of two weeks (or longer if exclusively used at night). Discontinuation is advised upon pain resolution, non-tolerance, significant daytime sedation, or the occurrence of other adverse effects.
Not recommended for mild to moderate acute neck pain due to concerns about adverse effects. Chronic use in subacute or non-acute neck pain (apart from acute exacerbations) is also discouraged.
Systemic Glucocorticosteroids (aka “Steroids”)
Recommended for select patients experiencing acute severe radicular pain syndromes to achieve short-term pain reduction. A tapering course of oral medication, such as methylprednisolone, for a duration of five to 14 days, is suggested for a specific episode of radicular pain. If further treatment is necessary, epidural steroid injections are preferable as they more precisely target the affected tissue.
Not recommended for axial pain or for cases of acute or non-acute neck pain without radicular pain or mild to moderate radiculopathy.
Intravenous steroids are recommended for select patients facing an acute neurological emergency but should be administered exclusively in a hospital setting. The dosage and duration of intravenous steroids should be determined in consultation with spinal cord experts. The urgency of addressing permanent neurological damage from acute spinal cord compression generally outweighs the risk of pharmacologic side effects of steroids in an emergency situation.
