Sports Pharmacology of Pain And Inflammation Control in Athletes

Types of Pain

The International Olympic Committee released a consensus on pain management that highlights the different types of pain.

• Nociceptive pain: associated with tissue damage or inflammation

• Neuropathic pain: lesion in the somatosensory nervous system

• Nociplastic/algopathic/nocipathic: neither nociceptive nor neuropathic; thought to be hypersensitivity secondary to altered nociceptive functioning

Management of Pain Principles From the International Olympic Committee Consensus Statement

• Early nonpharmacologic management, including implementation of biopsychosocial model for management

• Physical therapy, including modalities such as ultrasound, dry needling, iontophoresis, electric stimulation, and massage

• Psychological strategies should be encouraged, including muscle relaxation, guided imagery, and behavioral health therapy

• Medication management principles

  • Acute pain

  • Limit opioid or nonsteroidal anti-inflammatory drug (NSAID) prescriptions to 5 days and lowest effective dose

  • Subacute/chronic pain

  • Avoid chronic NSAID, acetaminophen, or opioid use

  • Consider a shift in focus from relieving pain to improving function

  • Multidisciplinary approach, including addressing the mental health burden of chronic pain

  • Consider adjunct medications

Prevalence

• NSAIDs are one of the most commonly used medications. In the US population, >29 million adults are estimated to be regular users of NSAIDs.

Mechanism of Action

• NSAIDs work by primarily inhibiting the cyclooxygenase (COX) pathway and, to a lesser extent, the lipoxygenase pathway, thereby blocking the conversion of arachidonic acid to prostacyclins, prostaglandins, and thromboxanes.

• Through this mechanism, NSAIDs exert antipyretic, analgesic, and anti-inflammatory actions.

• Blocking the production of certain prostaglandins causes NSAIDs to exert an inhibitory effect on neutrophil aggregation and lysosomal enzyme release.

• NSAIDs are also thought to have nonprostaglandin effects on limiting leukotriene synthesis via inhibition of membrane-related processes.

• The two main forms of COX, COX-1 and COX-2, are thought to have different functions ( Fig. 7.1 ).

  • COX-1 is presumably a constitutive enzyme involved in the synthesis of prostaglandins that regulate physiologic processes; it plays an important role in the function of the gastric mucosa, kidneys, vascular endothelium, and platelets.

  • COX-2, on the other hand, is primarily considered an inducible isoform (although data show that it may have a role in certain constitutive processes), involved in the synthesis of prostaglandins that mediate inflammation, pain, and fever in response to tissue injury.

  • The concept behind the development of COX-2–specific inhibitors was to theoretically preserve the physiologic function of COX-1 while limiting the effects of COX-2 on tissue injury.

  • Nonselective NSAIDs block both isoforms and subsequently may have more side effects than selective COX-2 inhibitors.

  

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