Musculoskeletal pain: pharmacological treatment


  • Stefano Guerrasio Dirigente medico I livello, Clinica Ortopedica, ASST-Monza, Ospedale San Gerardo



Pain treatment, musculoskeletal pain, multimodal treatment, paracetamol/codeine



Pain has the aim of identifying a harmful stimulus and avoiding tissue damage. Acute pain has recent onset and limited duration, while chronic pain is caused by continuous tissue damage or alteration in the pathways of transmission. Musculoskeletal pain is defined as acute and/or chronic pain affecting bones, muscles, ligaments, tendons and nerves. Medical literature about clinical aspects of pain, with particular focus on musculoskeletal pain, was reviewed and combined with expert opinion of the authors. The simultaneous use of drugs with different mechanisms of action (multimodal approach) allows a more effective analgesia with better tolerability. Paracetamol is a known molecule with analgesic and antipyretic activity, better tolerated than NSAIDs. Codeine is a natural opioid that inhibits transmission at the level of the spinal synapse and enhances the action of inhibitory descending pathways. The two drugs have a similar half-life, and the same time of onset and duration of analgesic activity. Many randomized studies have shown that this combination is more effective and better tolerated than NSAIDs and the combination of paracetamol/tramadol in different types of pain, i.e. postoperative, musculoskeletal, dental, headache, osteoarthritis, polytrauma. The Italian Intersociety group recommends the use of paracetamol and the combination paracetamol/codeine 500/30 mg, repeatable every 6 hours, for the management of moderate pain in the emergency setting.

Due to its safety and tolerability, paracetamol alone or in combination with codeine remains a first-choice treatment of mild-moderate pain, and its lack of cardiovascular and gastric toxicity represents a valid alternative to NSAIDs.