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Oral analgesics for acute nonspecific pain |
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BUY TRAMADOLAre you considering the option to buy Tramadol for your pain relief? Buy Tramadol offers a comprehensive guide to assist you in the important decision of whether or not Tramadol is the right choice for you, however please remeber it is important to always consult with a physician before taking any kind of medication. |
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American Family Physician, March 1, 2005 by Carolyn J. Sachs Physicians most often recommend or prescribe oral medication for relief of acute pain. This review of the available evidence supports the use of acetaminophen in doses up to 1,000 mg as the initial choice for mild to moderate acute pain. In some cases, modest improvements in analgesic efficacy can be achieved by adding or changing to a nonsteroidal anti-inflammatory drug (NSAID). The safest NSAID is ibuprofen in doses of 400 mg. Higher doses may offer somewhat greater analgesia but with more adverse effects. Other NSAIDs have failed to demonstrate consistently greater efficacy or safety than ibuprofen. Although they may be more expensive, these alternatives may be chosen for their more convenient dosing. Cyclooxygenase-2 inhibitors provide equivalent efficacy to traditional NSAIDs but lack a demonstrable safety advantage for the treatment of acute pain. For more severe acute pain, the evidence supports the addition of oral narcotic medications such as hydrocodone, morphine, or oxycodone. Specific oral analgesics that have shown poor efficacy and side effects include codeine, propoxyphene, and tramadol.
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Tramadol Approximately one half of the population reports pain or discomfort that persists continuously or intermittently for longer than three months. An even greater number of persons are likely to have acute pain at any one time. (1) Unfortunately, considerable confusion exists about the efficacy and safety of commonly used analgesics. This review provides a survey of the best available evidence regarding oral analgesia for acute pain, which is defined as pain associated with new tissue injury that typically lasts less than one month, but at times for as long as six months. (2) Acute pain generally does not involve the long-term, daily use of analgesics. Search Strategy Much of the literature on oral analgesics defines the efficacy of a specific analgesic as the proportion of patients who need to take that analgesic to experience at least a 50 percent reduction in pain compared with placebo. The concept of number needed to treat (NNT) is a particularly helpful way to convey this outcome. It refers to the number of patients who have to use the treatment for one patient to benefit. For example, when acetaminophen is said to have an NNT of four compared with placebo, it means that for every four patients who take acetaminophen instead of placebo, at least one patient will experience a 50 percent decrease in pain. The other three patients may have a significant decrease in pain (e.g., 40 or 30 percent), but this is not reflected in the NNT. The lower the NNT, the greater the likelihood that a given patient will achieve a 50 percent reduction in pain. (3) Other measures of pain relief include average decreases on visual analog scales and functional outcome measures. A visual analog scale is a 100-mm line with no pain at one end and severe pain at the other. For meaningful analgesia of acute pain, patients must report at least a 13-mm difference between analgesic choices. (4,5) This review focuses on the most commonly used oral analgesics for acute pain available in the United States: acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 (COX-2) inhibitors, tramadol (Ultram), and opiates. Acetaminophen Acetaminophen is a unique analgesic without a clearly defined mechanism. In a meta-analysis of 40 trials involving 4,171 patients comparing acetaminophen with placebo for postoperative pain, acetaminophen in a dose of 1,000 mg had an NNT of 4.6 (95 percent confidence interval [CI], 3.8 to 5.4) for at least 50 percent pain relief versus placebo. Lower doses were less effective. (6) Direct comparative studies between acetaminophen (1,000-mg dose) and NSAIDs show that NSAIDs are more effective than acetaminophen in some situations (e.g., dental and menstrual pain), but provide equivalent analgesia in others (e.g., orthopedic surgery and tension headache). (7,8) Aspirin Aspirin is an effective analgesic for acute pain, but it has not proved more effective than equal doses of acetaminophen. It also has a worse safety profile than acetaminophen. (9) Traditional NSAIDs EFFICACY NSAIDs are excellent analgesics with no clinically important difference in efficacy among specific drugs. (10) They are superior to acetaminophen for some types of pain, and in many acute pain settings they provide analgesia equal to usual starting doses of narcotics. (11) However, unlike narcotics that lack a ceiling dose, NSAIDs have a maximum dose above which no additional analgesia is obtained. Higher doses of NSAIDs may be used for anti-inflammatory effects. However, this review focuses only on doses used for analgesia. Strong evidence supports the use of nonprescription NSAIDs for dysmenorrhea and acute postpartum pain. In a meta-analysis (12) of randomized controlled trials (RCTs) of analgesics for dysmenorrhea, ibuprofen (Motrin) and naproxen (Aleve, Naprosyn) were equally effective, and both were better than acetaminophen and aspirin. For dysmenorrhea, acetaminophen was no better than placebo. Only naproxen had side effects worse than those of placebo. (12) Ibuprofen has shown similar effectiveness to a combination of acetaminophen, codeine, and caffeine for postpartum perineal pain with fewer side effects. (13) SAFETY AND ADVERSE EFFECTS Side effects may limit the use of NSAIDs. The most serious side effects include gastrointestinal (GI) bleeding and perforation, renal dysfunction, and platelet dysfunction. Ibuprofen provides an excellent GI safety profile that is not significantly different from placebo in dosages of 800 to 1,200 mg per day. (14) Higher prescription doses of naproxen and ibuprofen are associated with increased GI side effects similar to other prescription NSAIDs. (15) Epidemiologic data also support the use of 400 mg of ibuprofen first when choosing an NSAID. (16) Data from studies of subacute and chronic pain (osteoarthritis of the hip) therapy suggest that higher doses may provide better analgesia, but have more adverse effects. (17) [Histamine.sub.2] blockers, misoprostol (Cytotec), and proton pump inhibitors have been shown to reduce the risk of duodenal ulcers with daily NSAID use. (18) Only misoprostol (800 mg per day) has been shown to reduce the risk of other serious upper GI injury (i.e., perforation and/or bleeding). (19,20) The NNT with misoprostol to prevent one serious GI side effect is 264 patients. Based on a cost-effectiveness analysis, researchers concluded that misoprostol should be used only in high-risk patients. (21) COX-2 Selective NSAIDs EFFICACY Traditional NSAIDs inhibit cyclooxygenase-1 (COX-1) and COX-2 enzymes. Most of the analgesic effects of NSAIDs have been attributed to their COX-2 inhibition, while their undesirable side effects have been attributed to their inhibition of COX-1 enzymes. In recent years, three new oral prescription medications (celecoxib [Celebrex], rofecoxib [Vioxx], and valdecoxib [Bextra]) have been marketed in the United States; they selectively inhibit COX-2 enzymes without inhibiting COX-1 enzymes. Theoretically, these medications could provide analgesia equal to that of traditional NSAIDs without many of the side effects. A meta-analysis of the oldest COX-2 inhibitor, celecoxib, showed fair to good efficacy for postoperative pain with an NNT of 4.5 (95 percent CI, 3.3 to 7.2) compared with placebo. (22) In several RCTs, (23-26) rofecoxib has shown good analgesic efficacy for some acute pain conditions (e.g., joint replacement surgery, dysmenorrhea), but not for others (e.g., tonsillectomy, prostate biopsy). Valdecoxib (20 mg and 40 rag) has been effective for acute postoperative pain of wisdom tooth extraction with an NNT of 1.6 to 1.7. (27) Valdecoxib also has demonstrated analgesia superior to that of placebo in postoperative knee surgery. (28) Comparative trials have confirmed that COX-2 inhibitors are no more or less effective than NSAIDs. SAFETY AND ADVERSE EFFECTS |
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