NSAIDs and Acetaminophen
Scheduled NSAIDs + acetaminophen typically result in 30-40% reduction in opioid requirements for acute pain; this goes up even further if gabapentinoids are used.
Ketorolac is an NSAID with high COX-1 selectivity that is indicated to treat moderate to severe pain. It is available in IV, IM, and PO forms. Prior studies have found 30 mg of IM ketorolac to have similar analgesic efficacy as 12mg of IV Morphine. Its use in multimodal analgesia regimens provides significant opioid reduction and reduced side effects.
Gabapentin
For gabapentin, starting at 300 mg TID is reasonable for patients <70 years old, and 100 mg TID for those >70 years old. However, as gabapentin has a dose-response effect (albeit non-linear due to increased protein binding with increased dose), more rapid escalation in the inpatient setting is often done to quickly evaluate for efficacy while monitoring for side effects (e.g. sedation, dizziness).
Comparison of NSAIDs + Acetaminophen vs Opioids + Acetaminophen
Chang et al found that there were no clinically important differences in achieving analgesia from pain due to acute extremity injuries when given: 400mg Ibuprofen (e.g., Motrin™, Advil™) + 1000mg Acetaminophen (e.g. Tylenol™), 5mg Oxycodone/325mg Acetaminophen (e.g., Percocet), 5mg Hydrocodone/300 mg Acetaminophen (e.g., Lortab™, Norco™), or 30mg of codeine + 300mg of acetaminophen (e.g., Tylenol #3™).
Intravenous Opioids for Acute Pain
In the setting of acute pain, IV opioids should be reserved for scenarios in which the patient is unable to tolerate oral intake, requires strict NPO status, or for rescue analgesia for severe pain.
Long-acting Opioids for Acute Pain
Long-acting opioids should be avoided for acute pain treatment and only reserved for treating chronic pain, if at all. Some long-acting formulations have abuse-deterrent features that may reduce the marketability and likelihood of misuse.
References:
- McEvoy MD, Scott MJ, Gordon DB, et al. Perioperative Quality Initiative (POQI) I Workgroup.
American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on optimal analgesia within an enhanced recovery pathway for colorectal surgery: part 1-from the preoperative period to PACU. Perioper Med (Lond). 2017 Apr 13; 6:8
- Scott MJ, McEvoy MD, Gordan DB, et al. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on optimal analgesia within an enhanced recovery pathway for colorectal surgery: Part 2 – From PACU to the Transition Home. Perioper Med, 2017; Apr 13;6:7
- Yee JP, Koshiver JE, Allbon C, et al. Comparison of intramuscular ketorolac tromethamine and morphine sulfate for analgesia of pain after major surgery. Pharmacotherapy. 1986; 6: 253-61
- Cepeda MS, Carr DB, Miranda N, et al. Comparison of morphine, ketorolac, and their combination for postoperative pain: results from a large, randomized, double-blind trial. Anesthesiology. 2005; 103: 1225-32
- Oliveri L, Jerzewski K, Kulik A. Black box warning: is ketorolac safe for use after cardiac surgery? J Cardiothorac Vasc Anesth. 2014; 28:274-9.
- Chang AK, Bijur PE, Esses D, et al. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department A Randomized Clinical Trial. JAMA. 2017; 318(17):1661-1667.