New Direction – Part 4 Which pain medication is best for a specific type of pain?

In previous segments of this post we discussed the concept of Number Needed to Treat (NNT) and which medication or combination medication had the lowest NNT.  Surprisingly the medication with the lowest NNT was not an opioid.  It was Ibuprofen 200 mg + acetaminophen 500 mg:  The combination of these two OTC medicines provided the best pain relief of all, with an NNT of 1.6! Today we will examine some specific types of pain and the evidence based reviews of which medication is most effective.

Dental pain after wisdom tooth extraction.  Traditionally after a wisdom tooth extraction the patient would have been prescribed an opioid usually in combination with acetaminophen.  Several studies have been performed to ascertain if alternatives to opioids would be effective.  The Cochrane Collaboration reviewed studies comparing ibuprofen to acetaminophen.  They found that ibuprofen at all doses were more effective than acetaminophen, however in combination at six hours post procedure, the combination of the two was more effective.  It was found to consistently provide over 50% pain relief.

An article in the Journal of the American Dental Association concludes:“Combining ibuprofen with APAP provides dentists with an additional therapeutic strategy for managing acute postoperative dental pain. This combination has been reported to provide greater analgesia without significantly increasing the adverse effects that often are associated with opioid-containing analgesic combinations.”

Back pain.  In Dr. Teater’s article he discusses two reviews of treatment options for back pain.  A recent review in The Spine Journal found non-opioid medications provided some positive global effect while the opioids did not.  A second study by Dr. Radcliffe in 2013 found those receiving opioids for treatment of lumbar disc herniation had higher rates of surgery, significantly increased levels of pain and lower quality of life.

Severe Pain. There were not many studies evaluating pain relief methods in severe pain.  However a Cochrane Review of renal colic (the severe pain experienced with a kidney stone gets stuck in the ureter) pain examined the effectiveness of use of NSAIDs vs. opioids for pain relief.  In summary, NSAIDs and opioids can both significantly relieve the pain in acute renal colic, but opioids cause more adverse effects including vomiting.

Opioid medications are often referred to as powerful painkillers.  In fact, the evidence presented by Dr. Teater in his article shows that opioids are actually mild to moderate painkillers and less effective in many instances than OTC ibuprofen.  When they are as effective as NSAIDs and acetaminophen, they cause more harmful side effects.  Even if you ignore the societal issues created by chronic use of opioids, the lack of superior effectiveness demonstrates that opioids should not be the first line choice for pain relief.

In our next post we will examine some of the methods CompAlliance utilizes to educate and address the misconception that opioids should be first line treatment for pain.