Login
Subscribe
Pain control is an important goal of good-quality health care. Analgesic drug therapy is a key modality directed at pain control. Two situations in which oral analgesic medications are frequently prescribed for pain are upon discharge from the hospital and after outpatient surgery.
Among the most common medications used to control acute pain are nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids. Opioids are highly effective for acute pain but also highly addictive and further cause...
Pain control is an important goal of good-quality health care. Analgesic drug therapy is a key modality directed at pain control. Two situations in which oral analgesic medications are frequently prescribed for pain are upon discharge from the hospital and after outpatient surgery.
Among the most common medications used to control acute pain are nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids. Opioids are highly effective for acute pain but also highly addictive and further cause other adverse effects, including respiratory depression (slowed breathing), which can be deadly. NSAIDs, though generally safer than opioids, increase the risk of gastrointestinal and cardiovascular problems. Accordingly, pain management decisions often involve consideration of the relative risks and benefits of these two types of analgesics.
Two recently published studies strongly suggest that treatment of acute pain after hospitalization or after outpatient dental surgery is best achieved with NSAIDs rather than opioids.
Hospital discharge study
A study published online on Sept. 27, 2021, in PLOS Medicine analyzed a nationally representative sample of Medicare administrative claims data to compare adverse-event rates among older adults (aged 65 years and above) who filled a prescription for either an oral NSAID or an oral opioid within one week of discharge from a hospital.[1]
From the representative sample, the researchers identified a group of 13,385 patients who had filled an opioid prescription and a closely matched group of 4,677 patients who had filled an NSAID prescription. The two groups were matched using sophisticated statistical techniques to account for more than 100 factors potentially related to the choice of analgesic, including demographics (for example, age, gender, race and ethnicity), underlying medical diseases, type of surgeries and use of other (not NSAID or opioid) medications.
The Table below shows the five most common generic medications prescribed to each study group.
NSAIDs and Opioids Most Frequently Prescribed to Medicare Beneficiaries in 2016 Within One Week of Hospital Discharge in the PLOS Medicine Study
| Generic Name | Prescription Product Brand Name(s)† | Percent of Patients Within Drug Group†† |
|---|---|---|
| NSAID Group (4,677 patients) | ||
| meloxicam* | MOBIC | 28 |
| ibuprofen | generic only | 25 |
| celecoxib* | CELEBREX, ELYXYB | 19 |
| naproxen | ANAPROX DS, EC-NAPROSYN, NAPRELAN | 13 |
| diclofenac* | CAMBIA, CATAFLAM, ZIPSOR, ZORVOLEX | 7 |
| Opioid Group (13,385 patients) | ||
| hydrocodone | HYSINGLA ER | 40 |
| oxycodone** | OXAYDO, OXYCONTIN, XTAMPZA ER | 31 |
| tramadol* | CONZIP, QDOLO, ULTRAM | 22 |
| codeine** | generic only | 6 |
| morphine | MS CONTIN | 3 |
†Combination brand-name drug products excluded
††More than one drug prescription may have been filled by a single patient.
*Designated as Do Not Use by Worst Pills, Best Pills News
**Designated as Limited Use by Worst Pills, Best Pills News
The primary outcomes for comparison of patients in the NSAID and opioid groups included death, the need for emergency department (ED) use or rehospitalization, and a combined measure of other known adverse effects of NSAIDs or opioids. The other adverse effects in the combined measure were fall or bone fracture, delirium, nausea or vomiting, slowed colonic motility (constipation, impaction, intestinal obstruction), acute kidney failure and gastritis or duodenitis (inflammation of the stomach or initial part of the small intestine, respectively). All outcomes were assessed within 30 days of the original hospital discharge.
Patients who received opioids had a significantly higher incidence of death (2% versus 1%), ED visits or rehospitalization (19% versus 17%), and other adverse effects (25% versus 21%) than those in the NSAID group. Moreover, other individual adverse events previously related to opioid use were significantly more common in patients in the opioid group than those in the NSAID group; for example, fall/fracture occurred in 5% versus 3% and slow colonic motility occurred in 8% versus 6%, respectively. Adverse events tied to NSAIDs (kidney failure and gastritis or duodenitis) were not significantly different between the groups.
These findings led the study researchers to conclude that older adults filling an opioid analgesic prescription soon after a hospital stay were at higher risk of death and other adverse outcomes than those seeking similar pain relief with an NSAID only.
Dental surgery study
A randomized, double-blind, placebo-controlled trial evaluating the safety and effectiveness of an NSAID compared with an opioid for pain management after dental surgery was published online on Dec. 8, 2021, in Postgraduate Medicine.[2] The trial researchers randomly assigned 221 subjects, aged 18 to 26, to receive a single oral dose of one of the following immediately after the removal of three or four impacted third molars (wisdom teeth): the NSAID naproxen (90 subjects), the opioid hydrocodone combined with acetaminophen (87 subjects), or a placebo (44 subjects). They then assessed the change in pain intensity from zero to 12 hours following surgery and the frequency of all adverse events.
Subjects in the naproxen group had achieved significantly greater reductions in pain intensity at 12 hours than those in the hydrocodone/acetaminophen group. In addition, 63 adverse events (especially nausea, vomiting and dizziness) were seen in hydrocodone/acetaminophen-group subjects, 20 in placebo-group subjects and only two in naproxen-group subjects.
Based on these results, the researchers — who, it should be noted, were employed by naproxen’s maker — concluded that a single dose of naproxen is more effective and better tolerated for treating acute postsurgical dental pain than a single dose of an opioid combination drug.
What You Can Do
To manage moderate-to-severe acute pain, including pain following minor surgical procedures such as dental surgery, you should try to use oral NSAIDs and avoid opioids. You should not use an NSAID if you have had an allergic reaction to such drugs. Before using an NSAID, talk to your doctor or dentist about all your medical problems to make sure it is safe for you to take an NSAID. If you can tolerate NSAIDs, ibuprofen and naproxen are the best choices.
References
[1] Herzig SJ, Anderson TS, Jung Y, et al. Relative risks of adverse events among older adults receiving opioids versus NSAIDs after hospital discharge: A nationwide cohort study. PLoS Med. 2021 Sep 27;18(9):e1003804.
[2] Cooper SA, Desjardins PJ, Bertoch T, et al. Analgesic efficacy of naproxen sodium versus hydrocodone/acetaminophen in acute postsurgical dental pain: a randomized, double-blind, placebo-controlled trial. Postgrad Med. 2021 Dec 8:1-8. doi: 10.1080/00325481.2021.2008180. Online ahead of print.
