Post-operative pain management can be a concern of physicians and patients alike. Pain is subjective, making it difficult for physicians to decide which medications to recommend for patients with varying pain tolerances. There are many options of drugs to use, ranging from over-the-counter drugs like NSAIDs to prescription medications like low potency opioids.¹ Because of the adverse effects and potential for misuse associated with opioids, nonsteroidal anti-inflammatory drugs (NSAIDs) are an attractive alternative for post-operative pain management. NSAIDs work by inhibiting enzymes cyclooxygenase 1 and 2. Their potency and toxicity depend on the degree and permanence to which they inhibit enzymatic activity.

Multiple meta-analyses investigated the efficacy of NSAIDs use in the outpatient setting compared to opioids, specifically looking at the patient’s rating of post-operative pain using a 10-point intensity scale. At 6 hours and 12 hours after surgery, NSAIDs were associated with better pain scores, especially when acetaminophen was co-administered.³ These results are likely due to NSAIDs’ anti-inflammatory effects, which are useful for acute pain in the post-operative period. Additionally, NSAIDs were associated with fewer adverse events such as bleeding. Patients reported lower rates of nausea, vomiting, drowsiness, and headache.³ In contrast, opioids used for postoperative pain were associated with worse pain scores and often required increased repeat analgesic use.^3,4 Being prescribed opioids for postoperative pain was associated with increased long-term use of opioids, which can have many adverse effects physically and socially for patients.⁴

Providers may be concerned that NSAIDs will be inadequate for certain types of surgeries. Prospective clinical studies have shown that multimodal pain regimens are adequate at controlling patient pain for abdominal surgery and orthopedic surgery.^5,6 Typical pain regimens were ibuprofen and acetaminophen with prescriptions for 5 mg of oxycodone for breakthrough pain. Due to the increased awareness of the opioid epidemic, many patients were motivated to reduce opioid use post-operatively. Many patients did not fill or use their opioid prescriptions and still reported their pain to be adequately controlled.⁵ NSAIDs were shown to effectively manage post-operative pain and reduce opioid consumption in patients.²

Opioid stewardship is now more important than ever amidst the opioid epidemic. Outpatient prescription of opioids has played a significant role, making it important for providers to change their prescribing practices.⁵ In addition to using NSAIDs instead of solely relying on opioids, providers should counsel patients on realistic pain goals. It is unlikely a patient will have 0 out of 10 on the pain scale after surgery. They should expect some pain, though it should be tolerable enough to continue daily activities. Sim et al. found that, after laparoscopic abdominal surgery, the average visual analog pain score among 65 patients was 3.7 out of 10, and only four patients reported that their pain was not adequately controlled at home.⁵ Communication is key for managing postoperative pain expectations.

These studies are encouraging for physicians, who have to strike the difficult balance between adequate pain control post-operatively with patient safety and negative long-term effects. Fortunately, NSAIDs are associated with adequate pain control, reduced short term adverse effects, and lower risk of long-term dependence compared to opioids, making them an excellent option for pain control.

References 

1. Tawfic QA, Faris AS. Acute pain service: past, present and future. Pain Manag 2015;5:47–58. https://doi.org/ 10.2217/pmt.14.48 

2. Maund E, McDaid C, Rice S, et al. Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs for the reduction in morphine-related side-effects after major surgery: a systematic review. Br J Anaesth 2011; 106:292–7. https://doi.org/ 10.1093/bja/aeq406

3. Choi, M., Wang, L., Coroneos, C. J., Voineskos, S. H. & Paul, J. Managing postoperative pain in adult outpatients: a systematic review and meta-analysis comparing codeine with NSAIDs. Canadian Medical Association Journal 193, 2021. https://doi.org/10.1503/cmaj.201915

4. Chou R, Wagner J, Ahmed AY, Blazina I, Brodt E, Buckley DI, Cheney TP, Choo E, Dana T, Gordon D, Khandelwal S, Kantner S, McDonagh MS, Sedgley C, Skelly AC. Treatments for Acute Pain: A Systematic Review [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 Dec. Report No.: 20(21)-EHC006. https://effectivehealthcare.ahrq.gov/products/treatments-acute-pain/research 

5. Sim V, Hawkins S, Gave AA, Bulanov A, Elabbasy F, Khoury L, Panzo M, Sim E, Cohn S. How low can you go: Achieving postoperative outpatient pain control without opioids. J Trauma Acute Care Surg. 2019 Jul;87(1):100-103. https://doi.org/ 10.1097/TA.0000000000002295

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