NSAIDs outperform codeine for post-op pain

2 minute read

The anti-inflammatory properties of NSAIDs could be the key to reducing acute pain in post-operative outpatients.

As concern over opioid prescribing grows, so does the evidence base supporting non-opioid pain management, with new research suggesting nonsteroidal anti-inflammatory drugs (NSAIDs)  are more effective for pain post-surgery than low-potency opioids.

The meta-analysis, recently published in the Canadian Medical Association Journal, found NSAIDs were associated with better pain scores than codeine at six and 12 hours post-operation.

Codeine, a low-potency opioid, was frequently used for pain management post-surgery and had several common adverse effects, including nausea, vomiting, constipation, urinary retention and sedation.

However,  Australian researchers confirmed in 2019 that opioid initiation post-surgery led to chronic use in about 4% of patients.

Given the potential harms associated with chronic use, the Canadian team examined and compared 40 randomised control trials that looked at NSAIDs and codeine efficacy on self-reported pain levels.

Trials in which paracetamol was co-administered with either drug were also included in the analysis.

The research team found high-quality evidence in support of the efficacy of NSAIDs in pain management.

“In all surgery types, subgroups and outcome time points, NSAIDs were equal or superior to codeine for postoperative pain, with higher global assessments and fewer adverse effects,” the authors wrote in CMAJ.

In instances where paracetamol was co-administered, NSAID superiority reached clinical significance.

Furthermore, despite the common notion that NSAIDs could potentially increase risk of bleeding in post-operative patients, the researchers found evidence to the contrary.

“We found more bleeding or haematoma events with codeine treatment, although the event rates between the two treatments were not statistically different,” the authors said.

The effectiveness of NSAIDs over codeine in the post-operative setting was likely to relate to their mechanism of action, the authors suggested.

“We suspect that the anti-inflammatory mechanism of action of NSAIDs is better suited to the acute pain of postoperative patient.”

And it is likely these findings would be broadly generalisable across surgical disciplines, they concluded.

CMAJ 2021, June 14

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