The Rise of NSAIDs as Opioid Alternatives: a Case for Cautious Optimism

When it comes to pain management, you might find it surprising to learn that relatively few medication choices exist for the practitioner. For severe pain, the first class of drugs prescribed is usually opioid analgesics. But with the national opioid crisis, prescribers are increasingly searching for viable alternatives – which, by itself, is a good thing. Aside from opioids, anticonvulsants (like gabapentin), corticosteroids (such as prednisone and methylprednisolone), muscle relaxants (cyclobenzaprine, tizanidine, methocarbamol), and non-steroidal anti-inflammatories, known as NSAIDs (ibuprofen, meloxicam, naproxen, diclofenac, celecoxib) all have the potential to treat certain types of pain – but each comes with its own risks, as shown in the following table:


Analgesic Drug Adverse Effects Pain Indication
NSAIDs Cardiovascular (heart attack, stroke), Gastrointestinal (ulcers, bleeding), Renal system (kidney failure) Inflammation
Opioids CNS Depression (anxiety, confusion, depression, insomnia, respiratory failure), Gastrointestinal (constipation, nausea), Abuse potential Severe pain
Muscle Relaxants Cardiovascular (hypotension), CNS (confusion, drowsiness, dizziness, fatigue, irritability) Muscle spasms or spasticity
Corticosteroids Cardiovascular (hypertension), CNS (psychiatric disturbance, emotional lability, seizure), Endocrine (diabetes, fluid retention), Gastrointestinal (pancreatitis, peptic ulcer, ulcerative esophagitis), Infection, Osteoporosis, Wound Healing Impairment Inflammation
Anticonvulsants CNS (dizziness, drowsiness, fatigue, vertigo), Cardiovascular (peripheral edema), Endocrine (weight gain, hyperglycemia), Gastrointestinal (diarrhea, nausea/vomiting), Ophthalmic (blurred vision, double vision) Neuropathic (nerve) pain


Any of these drug classes in various combinations may be appropriate for pain management – with their use determined by the prescriber based on the patient’s unique physiological, biological and mental characteristics and accompanying drug regimen, weighed against any side or unintended effects. For example, an injured worker with diabetes and hypertension should avoid prednisone and NSAIDs, but when inflammation is present and such drugs are indicated, the strictest precautions must be taken to avoid adverse effects.


The choice to use opioids is not an easy one, as their misuse can lead to respiratory depression, overdose, and death. And while NSAIDs are increasingly being prescribed as an alternative, they can have their own adverse effects, including stomach bleeding, heart attack and stroke, all of which can be equally disastrous. Still, when an injured worker is at risk of misuse/abuse or overdose with opioids, alternatives should be considered.


Pain management is not an “absolute” practice and can be complicated. It is difficult to anticipate what treatment an individual will respond to and how various medication regimens will affect outcomes. For example, individuals taking over-the-counter cold remedies containing acetaminophen, aspirin or ibuprofen seldom consider how those drugs will affect prescription pain medications or other drugs they are taking. Such risks should be anticipated by the prescriber and discussed with the individual to prevent negative, even tragic outcomes. The recent downward trend in opioid utilization is a step in the right direction, but that step must be taken while considering that alternative drugs carry their own risks – and are not necessarily more effective or “automatically” safer.


Have questions regarding the use of opioids in workers’ compensation claims administration? KeyScripts can help. Call 866.446.2848 and ask to speak to a clinical pharmacist, or email schitwood@keyscriptsllc.com.


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