New York State Medical Treatment Guidelines for Medications For Non-acute Pain in workers compensation patients

The guidelines provided by the New York State Workers Compensation Board offer fundamental principles for administering medications to manage non-acute pain. These directives aim to assist healthcare professionals in selecting appropriate pharmaceutical interventions within the scope of comprehensive care.

Healthcare professionals with expertise in prescribing medications for non-acute pain can rely on the guidance outlined by the Workers Compensation Board to make well-informed decisions about the most suitable pharmaceutical treatments for their patients.

It is crucial to emphasize that these principles are not intended to replace clinical judgment or professional expertise. The administration of medications for non-acute pain should involve collaboration between the healthcare provider and the patient, considering individual factors such as medical history, medication efficacy, and potential side effects.


  • It’s important for clinicians to note the following considerations when interpreting the provided information:
    1. This list offers a concise overview of pharmacological options.
    2. The profiles of drugs within each class are not exhaustive.
    3. Dosing requirements may vary depending on the specific drug, especially for off-label use.
    4. Special caution should be exercised for pregnant or breastfeeding women, and consultation with a pharmacist or reference to standard medical texts is recommended for complete prescribing information.
  • The drug classes are presented alphabetically for ease of reference. However, this list is not intended to replace traditional medical resources or prescribing practices. It serves only as a guide.


Alpha-Acting Agents (e.g., clonidine)

  • Not Recommended: Due to limited experience with their use, they are not considered first-line or second-line analgesics. However, a trial of their use may be warranted in some cases of refractory pain.



  • Not Recommended: These are not suggested as first-line medications for non-acute pain. Patients on these medications should be closely monitored for suicidal ideation, hepatic and renal functioning, and potential medication interactions.
  • Not Recommended: For axial spine pain unless there’s evidence of a related neuropathic component. However, they may be considered for post-traumatic migraine headache.



  • Recommended: It’s suggested as a potential adjunct for chronic radicular or neuropathic pain after trying other treatments. Caution is advised due to its effect on hepatic enzymes, which may impact the metabolism of other drugs.



  • Recommended: For severe neurogenic claudication, chronic radicular pain syndromes, and neuropathic pain. It’s usually not superior to amitriptyline but can provide more effective pain relief when combined with tricyclics or opioids.
  • Recommended: Initiate at a low dose to minimize somnolence and titrate gradually. Maximum dosage is typically 1800 mg, occasionally up to 2400 mg per day.



  • Recommended: As a second-line agent for neuropathic pain after a trial of tricyclics. It’s approved for various neuropathic pain conditions and requires a gradual dose increase over several days.



  • Recommended: For limited use after multiple other modalities have failed. It’s considered a third- or fourth-line medication in appropriate patients.



  • Not Recommended: For most patients.



  • Antidepressants are categorized based on their chemical structure and effects on neurotransmitter systems. They can alleviate pain at lower doses and with shorter response times than those required for mood disorders.
  • Patients being considered for antidepressant therapy must be evaluated and monitored for suicidal ideation and mood swings. Many antidepressants may lower seizure threshold and cause secondary weight gain and fatigue.
  • To minimize side effects, it’s recommended to initiate antidepressants at a low dose and gradually increase as tolerated. Discontinuation requires careful attention due to potential withdrawal reactions, especially with certain medications like venlafaxine and tricyclics.
  • Antidepressants may help manage nocturnal sleep disruption, with tricyclic and tetracyclic antidepressants considered at bedtime doses lower than those for depression treatment.


Tricyclic Antidepressants (TCAs)

  • Recommended for radicular pain, though higher doses of amitriptyline may have more cholinergic side effects. Sedative effects are associated with doxepin and trimipramine.
  • Major contraindications include cardiac disease, glaucoma, seizures, and uncontrolled hypertension. Consideration of anticholinergic side effects is crucial, especially in older patients.


Selective Serotonin Reuptake Inhibitors (SSRIs)

  • Not recommended for neuropathic pain due to their primary use for depression. Combining SSRIs with moderate to high-dose tricyclics should be avoided due to the potential for serotonergic reactions.


Selective Serotonin Norepinephrine Reuptake Inhibitors (SSNRI/SNRI)

  • Not recommended as first- or second-line treatments. Reserved for patients who fail other treatments due to side effects. Duloxetine is FDA approved for diabetic neuropathic pain and fibromyalgia, while milnacipran is approved for fibromyalgia.


Atypical Antidepressants/Other Agents

  • Recommended for depression but not for neuropathic pain.


Compound Medications

  • Not recommended, including topical, oral, and systemic medications.



  • Not recommended.


Hypnotics and Sedatives

  • Not recommended due to addiction potential, withdrawal symptoms, and sedating side effects, especially when used with chronic opioids. Behavioral interventions should be the primary approach for managing insomnia.


Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Non-Acute Pain

  • For most patients, older generation NSAIDs like ibuprofen and naproxen are recommended as first-line medications. Acetaminophen may be an alternative, although slightly less effective.
  • NSAIDs are as effective as opioids for pain relief but have fewer impairing effects. Over-the-counter agents can suffice for many patients and should be tried first.
  • NSAIDs should be discontinued when symptoms resolve, efficacy is lacking, or adverse effects develop.


NSAIDs for Patients at High Risk of Gastrointestinal Bleeding

  • For patients at high risk of gastrointestinal bleeding, cytoprotective medications like misoprostol and proton pump inhibitors are recommended alongside NSAIDs.
  • Cytoprotective medications should be considered for patients with a high-risk profile, such as those with a history of gastrointestinal bleeding, elderly patients, diabetics, and smokers.


NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

  • Patients with cardiovascular disease or risk factors should discuss the risks and benefits of NSAID therapy. Acetaminophen or aspirin may be safer first-line options.
  • Non-selective NSAIDs are preferred over COX-2 specific drugs. NSAIDs should be timed with low-dose aspirin to minimize counteraction of its beneficial effects.


Acetaminophen for Treatment of Non-Acute Pain

  • Acetaminophen is recommended for non-acute pain, especially in patients with NSAID contraindications. It should be used according to the manufacturer’s recommendations to avoid hepatic toxicity.
  • Discontinuation should occur when pain resolves, adverse effects develop, or intolerance occurs.


Topical Medications

  • Topical medications like lidocaine patches and capsaicin creams may be suitable for selected patients. They offer localized relief with potentially fewer systemic side effects.
  • Prescribers should provide strict instructions for application and monitor for potential toxicity. Long-term use of these agents is generally not recommended.
  • Topical NSAIDs like diclofenac gel may be beneficial, especially when systemic administration is contraindicated.
  • Topical salicylates may be used as an adjunct to systemic medication for short-term relief, particularly in patients with chronic conditions.


N-Methyl-D-Aspartic Acid Receptor Antagonists (e.g., ketamine)

  • Not recommended for oral or dermal use.


Selective Cyclo-oxygenase-2 (COX-2) Inhibitors

  • COX-2 inhibitors are recommended for select patients who cannot tolerate traditional NSAIDs but should not be the first-line choice for low-risk patients using NSAIDs short-term.
  • Patients should take the lowest effective dose of COX-2 inhibitors for the shortest duration necessary.
  • COX-2 inhibitors offer advantages over traditional NSAIDs by causing less gastrointestinal (GI) toxicity and no platelet effects.
  • However, serious upper GI adverse events can still occur, especially in high-risk patients with a history of prior GI bleed, diabetes, alcohol use, smoking, corticosteroid or anticoagulant use, older age, or prolonged therapy.
  • Caution is advised when using celecoxib with aspirin to ensure proper dosing intervals.
  • COX-2 inhibitors may worsen renal function in patients with renal insufficiency, requiring monitoring.
  • They should be used cautiously in patients with ischemic heart disease and/or stroke and avoided in those with risk factors for coronary heart disease. Acetaminophen, aspirin, or non-selective NSAIDs are safer first-line options for these patients.
  • Celecoxib is contraindicated in patients allergic to sulfonamides.


Skeletal Muscle Relaxants

  • Recommended for acute musculoskeletal injuries or exacerbations but not for chronic use due to their potential for habit formation, severe sedation, seizure risk upon abrupt withdrawal, and documented contribution to respiratory depression in patients on chronic opioids.
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