Nonopioid, Multimodal Analgesia as First‐line Therapy After Otolaryngology Operations: Primer on Nonsteroidal Anti‐inflammatory Drugs (NSAIDs)

Abstract

Objective To offer pragmatic, evidence-informed advice on nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy after surgery. This companion to the American Academy of Otolaryngology–Head & Neck Surgery (AAO-HNS) clinical practice guideline (CPG), “Opioid Prescribing for Analgesia After Common Otolaryngology Operations,” presents data on potency, bleeding risk, and adverse effects for ibuprofen, naproxen, ketorolac, meloxicam, and celecoxib. Data Sources National Guidelines Clearinghouse, CMA Infobase, National Library of Guidelines, NICE, SIGN, New Zealand Guidelines Group, Australian National Health and Medical, Research Council, TRIP database, PubMed, Guidelines International Network, Cochrane Library, EMBASE, CINAHL, BIOSIS Previews, ISI Web of Science, AHRQ, and HSTAT. Review Methods AAO-HNS opioid CPG literature search strategy, supplemented by PubMed/MEDLINE searches on NSAIDs, emphasizing systematic reviews and randomized controlled trials. Conclusion NSAIDs provide highly effective analgesia for postoperative pain, particularly when combined with acetaminophen. Inconsistent use of nonopioid regimens arises from common misconceptions that NSAIDs are less potent analgesics than opioids and have an unacceptable risk of bleeding. To the contrary, multimodal analgesia (combining 500 mg acetaminophen and 200 mg ibuprofen) is significantly more effective analgesia than opioid regimens (15 mg oxycodone with acetaminophen). Furthermore, selective cyclooxygenase-2 inhibition reliably circumvents antiplatelet effects. Implications for Practice The combination of NSAIDs and acetaminophen provides more effective postoperative pain control with greater safety than opioid-based regimens. The AAO-HNS opioid prescribing CPG therefore prioritizes multimodal, nonopioid analgesia as first-line therapy, recommending that opioids be reserved for severe or refractory pain. This state-of-the-art review provides strategies for safely incorporating NSAIDs into acute postoperative pain regimens.

Clinical Knowledge and Trends in Physicians' Prescribing of Opioids for New Onset Back Pain, 2009-2017

“…To our knowledge, this reflects the continued challenge of opioid overprescribing and the relatively limited options for effective pain control in musculoskeletal care. 13,39 In 2018, one-quarter of adults 65 years and older were prescribed an opioid. 10 This is the first study to examine the differential association between physician knowledge and opioid prescribing during periods before and after opioid guidelines were changing.…”

Multimodal Analgesia in Head and Neck Free Flap Reconstruction: A Systematic Review

“…When comparing with literature, multiple consensus guidelines strongly recommend the use of NSAIDs for postoperative pain control. 33,34 Regardless, high-quality RCTs with large sample sizes are still lacking, likely due to continued provider hesitancy to add NSAIDs to a standard postoperative pain regimen.…”

Is otologic surgery contributing to the opioid epidemic?

“…Nevertheless, we believe that this questionnaire based analysis provides important aspects and insights to possibilities of non-opioid therapy for postoperative pain. As mentioned above, in several other surgical fields sufficient postoperative pain control with NSAIDs comparable or even superior to opioids has been shown in randomized studies and meta-analyses [ 16 , 17 , 24 , 25 ]. Primarily, treatment of pain following otologic surgery should therefore be attempted without opioids.…”