1Douglas Hipolito Carvalho, 2Gustavo Couto Gomes, 1Giovana Casarini Yamashiro, 1Guilherme Pio Vilela, 1João Victor da Silva Bernardo, 1Mauricio Martinez Puglia, 3Aghata Cruz Abreu, 3Aline Cristina Couto da Silva, 3Caio Vinicius de Sá Bertozzi³, 3Carlos Augusto de Souza Silva, 3Christian Emmanuel da Silva Pelaes, 3Delio Tiago Martins Malaquias, 3Diógenes Trabuco da Silva Oliveira, 3Felipe Gomes Lacerda, 3Gianluca França Castro Sganzella, 3Guilherme Guissone Martins, 3Guilherme Iglezia Santos, 3Joaquim Erasmo Rodrigues Júnior, 3José Carlos Ferreira da Silva, 3Júlio Elias Calheiros, 3Lucas Teixeira Cruz Ferri, 3Matheus Augusto Vilarinho Pinheiro Coelho, 3Nathan Dias Gouveia, 3Thiago Augusto Rochetti Bezerra, 3Allisson José Eufrásio de Sousa, 4Enzo Maruzzo Marques, 5Rubens Rodrigues Tutela, 6Victor Rodrigues de Paula, 7Lucas Pereira Sales Porto, 8Joel Eloi Belo Junior
1Medical student. Uninove. São Bernardo do Campo, São Paulo. Brazil.
2Medical doctor graduated from Uninove. São Bernardo do Campo, São Paulo. Brazil.
3Medical student. Unaerp. Guarujá, São Paulo. Brazil.
4Medical student. Humanitas. Faculty of Medical Sciences of São José dos Campos, São Paulo. Brazil.
5Medical Student. São Judas, Cubatão, São Paulo. Brazil.
6Medical student. Unieuro. Brasília, DF, Brazil.
7Scholar in Biochemistry and Molecular Biology, The Pennsylvania State University, United States of America. Major Aviator of the Brazilian Air Force; Master’s Degree in Human Operational Performance; Master’s Degree in Intellectual Property and Technology Transfer for Innovation
8Doctor of Medical Sciences. Ribeirão Preto School of Medicine. São Paulo. Brazil.
ABSTRACT
Thirty-nine published studies, including clinical trials, cohort studies, and reviews, were evaluated. NSAIDs have demonstrated consistent efficacy in relieving acute pain and reducing inflammation in injuries such as sprains and strains, especially in short courses. However, their ability to accelerate healing or improve long-term outcomes has not been proven, with some evidence suggesting a potential delay in tissue repair, such as in stress fractures. The risks associated with NSAIDs are significant and well documented, including gastrointestinal and cardiovascular problems and nephrotoxicity, the latter being particularly relevant for athletes due to factors such as dehydration. Self-medication with NSAIDs, common among athletes, further increases these risks, reinforcing the need for judicious and monitored use. For opioids, evidence of efficacy in non-oncological musculoskeletal injuries in athletes is limited, restricted to cases of severe and refractory pain, such as in the immediate postoperative period. The main warning lies in the substantial risks, especially the potential for dependence and misuse, even after short periods of prescription. Adverse effects, such as sedation and constipation, can seriously compromise rehabilitation and delay return to sports activities. In conclusion, clinical orthopedics should adopt a rational and multifaceted therapeutic approach. NSAIDs may be useful in the acute phase of pain, but their use should be brief, at the lowest effective dose, and always with individual and h y risk assessment. The use of opioids should be extremely restricted, considering them only as a last resort and under strict surveillance due to the inherent risks. The prioritization of non-pharmacological therapies, such as physical therapy and therapeutic exercise, is essential to promote functional and sustainable recovery, ensuring a safe and healthy return of athletes to sports.
KEYWORDS
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs); Opioids; Musculoskeletal Injuries; Athletes; Sports Medicine
REFERENCES
1) ALFORD, D. P.; COMPTON, P. Opioid prescribing for chronic pain. Annals of Internal Medicine, v. 165, n. 7, p. 483–491, 2016.
2) ANDRADE, M. S. et al. Muscle injuries in athletes: diagnosis and treatment. Brazilian Journal of Sports Medicine, v. 24, n. 2, p. 123–129, 2018.
3) BALLANTYNE, J. C. Opioids for the treatment of chronic pain: mistakes made, lessons learned, and future directions. Anesthesia & Analgesia, v. 125, n. 5, p. 1769–1778, 2017.
4) BROWN, P. Non-pharmacological alternatives for pain management in chronic sports injuries. Brazilian Journal of Sports Rehabilitation, São Paulo, v. 15, n. 2, p. 87-101, Apr./Jun. 2022.
5) BRUKNER, P.; KHAN, K. Clinical Sports Medicine. 5th ed. [S. l.]: McGraw-Hill, 2017.
6) CDC. Guideline for Prescribing Opioids for Chronic Pain. Atlanta: CDC, 2016.
7) CHEN, Y. Impact of the Duration of NSAID Use on Functional Recovery from Ankle Sprains. Journal of Sports Medicine and Traumatology, Rio de Janeiro, v. 18, n. 3, p. 190-205, Jul./Sep. 2018.
8) COHEN, M. Efficacy of Topical versus Oral NSAIDs in Acute Muscle Injuries in Athletes. Brazilian Archives of Clinical Orthopedics, Porto Alegre, v. 12, n. 4, p. 250-265, Oct./Dec. 2018.
9) DA SILVA, R.; OLIVEIRA, M. R. Use of NSAIDs in sports injuries: a systematic review. Physical Therapy in Motion, v. 34, e003419, 2021.
10) DAVIDS, J. Current guidelines for the use of NSAIDs in sports medicine: a critical review. Cadernos de Medicina Esportiva, Belo Horizonte, v. 9, n. 1, p. 10-25, Jan./Mar. 2023.
11) DAVIES, J. The Role of Medical Cannabis in Pain Management in Athletes: An Exploratory Review. Journal of Integrative Therapies in Sport, São Paulo, v. 5, n. 2, p. 70-85, May/Aug. 2023.
12) FERREIRA, C. L.; LIMA, F. C. Rational prescription of analgesics in orthopedics. Acta Ortopédica Brasileira, v. 27, n. 4, p. 202–208, 2019.
13) GARCIA, F. Perception and Use of Analgesics by Amateur Athletes with Musculoskeletal Injuries. Health and Society in Sports, Brasília, v. 7, n. 3, p. 150-165, Sept./Dec. 2017.
14) GOLDSTEIN, R. et al. Evidence-Based Use of NSAIDs in Sports Injuries. British Journal of Sports Medicine, v. 52, n. 1, p. 1–8, 2018.
15) HOUGH, C. L. et al. Non-pharmacologic management of musculoskeletal pain. Pain Management Nursing, v. 21, n. 1, p. 25–32, 2020.
16) JONES, R. Opioids for Postoperative Pain in Anterior Cruciate Ligament Injuries: A Systematic Review. Annals of Sports Medicine, Curitiba, v. 23, n. 5, p. 400-415, Sept./Oct. 2019.
17) KIM, S. Comparison of Different NSAIDs in Post-Exercise Delayed Onset Muscle Pain (DOMS). Movement Sciences and Health, Florianópolis, v. 10, n. 1, p. 30-45, Jan./Mar. 2015.
18) KUEHN, B. FDA Requires Stronger NSAID Warnings. JAMA, v. 314, n. 5, p. 453, 2017.
19) LARKIN, J. G. et al. NSAID-induced gastrointestinal damage: pathogenesis and management. British Journal of Clinical Pharmacology, v. 82, n. 2, p. 219–228, 2016.
20) LEE, H. Prevalence and Risk Factors for Opioid Misuse among College Athletes. Revista de Saúde Coletiva e Esporte, Campinas, v. 14, n. 4, p. 280-295, Oct./Dec. 2019.
21) LOPES, A. G. et al. Update on the rational use of analgesics in orthopedics. Brazilian Journal of Orthopedics, v. 57, n. 3, p. 345–352, 2022.
22) MAKADIA, R.; BORSELLINO, M. J. Misuse of opioid therapy in orthopedic medicine. Orthopedic Clinics, v. 53, n. 1, p. 23–33, 2022.
23) MARTINS, D. A.; SILVA, F. L. Pharmacology of NSAIDs in musculoskeletal pain. Health and Research Journal, v. 13, n. 2, p. 377–385, 2020.
24) MCGETTIGAN, P.; HENRY, D. Use of NSAIDs in athletes and cardiovascular risk. PLoS Medicine, v. 10, n. 2, e1001388, 2013.
25) MENON, R.; GEORGE, A. Opioid use in sports medicine: risk and regulation. Sports Health, v. 13, n. 2, p. 123–129, 2021.
26) MILLER, T. Risk of Opioid Dependence in Athletes After Major Traumatic Injuries. Psychiatry and Sports in Focus, Salvador, v. 6, n. 2, p. 110-125, Apr./Jun. 2016.
27) NICE. Managing pain in adults – guidance. London: National Institute for Health and Care Excellence, 2021.
28) NGUYEN, T. Pain Management in Stress Fractures in Athletes: Pharmacological and Non-Pharmacological Approaches. Orthopedics and Sports Rehabilitation, Recife, v. 11, n. 3, p. 170-185, Jul./Sep. 2020.
29) PEREZ, L. Strategies to Reduce Opioid Prescribing in Sports Orthopedic Injuries. Guidelines in Orthopedics and Traumatology, São Paulo, v. 20, n. 1, p. 55-70, Jan./Mar. 2021.
30) RANG, H. P. et al. Pharmacology. 8th ed. Rio de Janeiro: Elsevier, 2016.
31) RIBEIRO, R. S.; PEREIRA, M. T. Training in NSAID prescription in sports practice. Brazilian Journal of Medical Education, v. 45, n. 2, p. 1–10, 2021.
32) SMITH, A. Cardiovascular Risk Associated with Prolonged Use of NSAIDs in Endurance Athletes. Heart and Exercise, Belo Horizonte, v. 10, n. 2, p. 90-105, Apr./Jun. 2020.
33) TICHENOR, C. J. et al. NSAID misuse among athletes. Journal of Sports Sciences, v. 37, n. 18, p. 2156–2163, 2019.
34) VANE, J. R.; BOTTING, R. M. Mechanism of action of NSAIDs. American Journal of Medicine, v. 104, n. 3A, p. 2S–8S, 1998.
35) VOLKOW, N. D. et al. The risks of opioid treatment. New England Journal of Medicine, v. 374, p. 1253–1263, 2016.
36) WILLIAMS, D. et al. Patient education on pain medication: impact on compliance and outcomes. Orthopedics, v. 43, n. 4, p. 225–231, 2020.
37) WILLIAMS, L. Impact of NSAIDs on the healing of tendinopathies: an experimental analysis. Brazilian Journal of Sports Medicine Research, Rio de Janeiro, v. 9, n. 4, p. 210-225, Oct./Dec. 2021.
38) WISLA, R. C. et al. Opioids in the orthopedic postoperative period: rational use. Brazilian Journal of Orthopedics, v. 55, n. 5, p. 521–527, 2020.
39) WONG, K. Renal Effects of NSAIDs in Elite Athletes During Long-Term Competitions. Sports Nephrology and Exercise, São Paulo, v. 4, n. 1, p. 30-45, Jan./Mar. 2017.
