WASHINGTON, D.C.—Occupational strains and sprains are common presentations to the emergency physician. At the same time, there is significant attention being paid to the use and overuse of opioid medications in the management of pain. No wonder: Studies show that patients with occupational lower back pain who are prescribed opioids early are more likely to receive MRIs, more likely to have surgery, and more likely to be disabled one year after incident. Moreover, more than 6 percent will still be on an opioid medication after one year.

There are other ways to manage lower back pain without resorting to opioids, according to Alexis M. LaPietra, DO, medical director of the emergency medicine pain management program and the fellowship director of the emergency medicine pain management fellowship at St. Joseph’s Regional Medical Center in Paterson, New Jersey.

One approach is to layer several non-opioid pain medications. Begin by using tried and true NSAIDS. Studies show that naproxen alone achieves the same level of pain control when compared to combinations of naproxen and oxycodone or flexeril. Moreover, a 400-mg dose is thought to be ideal, as the analgesic ceiling is reached at that range. If that doesn’t achieve the desired response, consider adding acetaminophen. The combination of the two has been shown to achieve better control of postoperative and dental pain than either one alone. Another layer of medication to add are topicals. Lidocaine patches or diclofenac gel or patches have been shown to be effective at controlling localized muscular pain.

Osteopathic manipulative therapy (OMT) is another approach to consider. This technique stretches and realigns muscles and tendons and takes advantage of the body’s natural ability to heal. In one study, OMT was shown to achieve similar results in pain control when compared to intramuscular ketorolac. Any medical or osteopathic physician can perform these procedures, they take little time to perform, and are reimbursable with appropriate documentation.

For focal nodular spasms, trigger point injections can be successfully used to release the tension and reduce the pain. The nodule is isolated during assessment, and a 21 to 25 g needle with a local anesthetic is introduced at a 30-degree angle into the center of the nodule. The needle is then partially withdrawn and reinserted several times at different angles, breaking up the fibers and releasing the tension. This procedure is reimbursable as well and has produced remarkable results in diminishing severe pain quickly.