Analgesia and Anti-Inflammatories

There is no single analgesic that suits every problem, and choice follows the diagnosis. For osteoarthritis, current UK guidance advises offering a topical non-steroidal anti-inflammatory drug (NSAID) for knee osteoarthritis and considering one for osteoarthritis at other joints, because topical treatment delivers drug to the area with much less systemic exposure than tablets. An oral NSAID is considered when topical treatment is ineffective or unsuitable, after weighing gastrointestinal, kidney, liver and cardiovascular risk, and for osteoarthritis it is offered with gastroprotection such as a proton pump inhibitor; in other settings the need for gastroprotection follows an individual risk assessment and current formulary guidance. Selective cyclo-oxygenase-2 (COX-2) inhibitors are one class of oral NSAID. Topical NSAIDs are a useful option for some localised soft-tissue pain, but they are not a universal first-line treatment for every such presentation.

Paracetamol and opioids are treated cautiously and by condition. For osteoarthritis, paracetamol and weak opioids are not offered routinely, and may be considered only for infrequent short-term use when other options are unsuitable, ineffective or not tolerated, while strong opioids are not offered for osteoarthritis at all. For chronic low back pain, paracetamol alone and opioids are not recommended, though a weak opioid has a limited role in some cases of acute low back pain. For pain with a clear neuropathic component, the options are amitriptyline, duloxetine, gabapentin or pregabalin (with certain conditions such as trigeminal neuralgia and sciatica following separate guidance), and treatment is reviewed for benefit, adverse effects, and the risk of dependence and withdrawal. Duloxetine is used for neuropathic pain but is not a routine recommended option for osteoarthritis pain in current UK guidance. Throughout, physical treatments, activity and rehabilitation remain central, since medication supports recovery rather than replacing it.

NSAIDs reduce pain and inflammation by inhibiting cyclo-oxygenase (COX) enzymes and the production of prostaglandins, but inflammation is also part of normal healing, which raises a genuine question about their effect on tissue repair. The evidence is mixed rather than settled. There is a theoretical and experimental concern that NSAIDs may impair bone healing, but the evidence does not justify avoiding them in all fractures and bone stress injuries as a blanket rule. The sensible approach is case-by-case: a short course to control pain and allow rehabilitation can be reasonable, while unnecessary prolonged or high-dose use is avoided where bone healing is a particular concern, such as in a significant bone stress injury or a fracture at risk of poor union. Effects on tendon, ligament and muscle healing are less clear, with some short-term benefit for pain and function balanced against a possible blunting of the tissue's adaptation to loading.

The practical position is one of balance and of using the least medication needed to enable rehabilitation. This is one reason that anti-inflammatory drugs are not simply given for every injury by default, and why the decision weighs the benefit of comfort and earlier movement against the possible cost to healing in that particular case.

Prescribing for athletes carries an extra layer, because some pain-relieving drugs are controlled under the World Anti-Doping Agency (WADA) rules, and status depends on the drug, the route and whether it is in or out of competition. Most NSAIDs and paracetamol are permitted at all times. Glucocorticoids are prohibited in-competition when given by injectable, oral or rectal routes, and a local route such as an intra-articular injection still counts as injectable and is caught by this rule; the applicable washout period and the exact product must be checked before use. Among opioids, specified narcotics, including tramadol, are prohibited in-competition; codeine is not currently prohibited, although it is on the monitoring programme, so pain relief near competition is planned with care.

Two points guide safe practice. First, whether a therapeutic use exemption (TUE) is required depends on the athlete's level of competition and their anti-doping organisation, so it is not automatically needed every time any athlete is prescribed a listed medicine; where one is required it is applied for prospectively, with retrospective applications allowed only in defined circumstances such as emergency or insufficient time. A prescription by itself does not make a prohibited substance permitted. Second, every medicine is checked before use against the current rules, for example using Global Drug Reference Online, and permitted options and non-drug treatments are chosen where possible, with timing planned around competition and clear records kept. For the SEM clinician, integrating this check into everyday prescribing protects the athlete from an inadvertent violation while still treating their pain effectively.

• •For osteoarthritis, offer a topical NSAID for the knee and consider one at other joints; consider an oral NSAID with gastroprotection if topical treatment is ineffective or unsuitable, after risk assessment.
• •For osteoarthritis, paracetamol and weak opioids are not routine (only infrequent short-term use if other options fail) and strong opioids are not offered; for chronic low back pain, paracetamol alone and opioids are not recommended.
• •Neuropathic pain options are amitriptyline, duloxetine, gabapentin or pregabalin, with review for benefit, adverse effects and dependence; duloxetine is not a routine option for osteoarthritis.
• •NSAIDs may impair bone healing, so use is case-by-case: avoid unnecessary prolonged or high-dose treatment where bone healing is a concern, rather than avoiding them in every fracture.
• •Most NSAIDs and paracetamol are permitted in sport; glucocorticoids are prohibited in-competition by injectable, oral or rectal routes (check washout and product), and specified narcotics including tramadol are prohibited in-competition.
• •A prescription alone does not permit a prohibited substance; whether a therapeutic use exemption is needed depends on the athlete's competition level and anti-doping organisation.