Non-selective and
cyclooxygenase-2 (COX-2) selective non-steroidal anti-inflammatory drugs (
NSAIDs) have been the mainstay of treatment for
musculoskeletal pain of moderate intensity. However, in addition to gastrointestinal and renal toxicity, an increased cardiovascular risk may be a class effect for all
NSAIDs. Despite these safety risks and the acknowledged ceiling effect of
NSAIDs, many doctors still use them to treat moderate, mostly
musculoskeletal pain. Recent guidelines for treating
osteoarthritis and
low back pain, issued by numerous professional medical societies, recommend
NSAIDs and
COX-2 inhibitors only in strictly defined circumstances, at the lowest effective dose and for the shortest possible period of time. These recent guidelines bring more focus to the usage of
paracetamol and
opioids. But
opioids still remain under-utilized, although they are effective with minimal organ toxicity. In this setting, the atypical, centrally acting
analgesic tramadol offers important benefits. Its multi-modal effect results from a dual mode of action, ie,
opioid and monoaminergic mechanisms, with efficacy in both nociceptive and
neuropathic pain. Moreover, fewer instances of side effects such as
constipation,
respiratory depression, and sedation occur than with traditional
opioids, and
tramadol has been prescribed for 30 years for a broad range of indications.
Tramadol is now regarded as the first-line
analgesic for many musculoskeletal indications. In conclusion, it is recommended to better implement the more recent guidelines focusing on
pain management and consider the role of
tramadol in
musculoskeletal pain treatment strategies.