I believe if we took a poll of doctors, nurses, claims professionals, employers, and injured workers most would state their belief that opioids are stronger than other pain medications (NSAIDs or acetaminophen).

Several organizations have reviewed the comparative effectiveness of oral pain medications.  In part 2 of this series, I provided a link to the Oxford League Table of Analgesics .   This is a listing of oral pain medications and their Number Needed to Treat (NNT).  Another organization that has performed an evidence based review of oral pain medications is the Cochrane Collaboration. The Cochrane Collaboration states on their website: “Cochrane exists so that healthcare decisions get better. During the past 20 years, Cochrane has helped to transform the way health decisions are made. We gather and summarize the best evidence from research to help you make informed choices about treatment.”

Several Cochrane reviews have examined the treatment of postoperative pain. Postoperative pain is often studied because it is an objective example of tissue trauma resulting in pain.  It occurs in a controlled environment where rigorous experimental protocols can be followed.  I know that for a fact as I participated back in the 80’s in an experimental trial for effective pain relief methods post C-section.

What are the findings?  (Keep in mind the concept of Number Needed to Treat (NNT) as discussed in Part 2 of this series):

Oxycodone 15 mg:  The NNT is 4.6.  Imagine you would need to treat 46 people for 10 to get 50% relief of their pain.  Thirty-six of those 46 would not get adequate pain relief.

Oxycodone 10 mg + acetaminophen 650 mg (equivalent to two Percocet pills).  The NNT is 2.7.  The acetaminophen adds significant benefit.

Naproxen 500 mg (OTC Aleve):  The NNT for this is also 2.7.  Naproxen is not an opioid.  It is an NSAID.

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!

Bandolier is another independent organization in Europe that produces reports on evidence based medicine.  Bandolier issued a report in 2003 on the treatment of acute pain.  Dr Teater in his article on the Evidence for the efficacy of pain medications also refers to an additional table by Bandolier produced in 2007, comparing the relative strengths of some commonly used medications.  In summary he notes an injection of 10 mg morphine is roughly equivalent to an oral dose of OTC ibuprofen.

Dr. Teater further goes on to state, and I agree based on the evidence I have presented above, it is apparent the pharmaceutical companies have done such a great job at marketing opioids that many of us have come to believe opioids are actually stronger than other medications.  The facts do not bear out that belief.

In future posts I will summarize evidence based approaches to pain relief for different types of acute and chronic pain and how we can all work together to address these misconceptions.