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Top Reasons Why NSAIDs Should Be the New Hydrocodone

by Dr. Sharon Orrange on October 21, 2014 at 2:51 pm

Pain is complex, so there is no “one pill fits all” treatment. Hydrocodone is the most prescribed medication in the United States, also marketed in combination with acetaminophen (Tylenol) under the brand names Vicodin, Norco and Lortab.

As of October 6, 2014, all drugs containing hydrocodone are schedule II drugs, and that means they are now much harder to get. There is no question this is a hassle for some patients and physicians but we (doctors) are too quick to prescribe it and for most pain, you don’t really need hydrocodone.

  • Is hydrocodone better than over the counter pain meds?In many studies done on specific types of pain: acute or chronic, musculoskeletal or postoperative among others, non-opioid medications were just as good if not better.You see, the classic line taught in medical school is that NSAIDS/non steroidal anti-inflammatory drugs (ibuprofen, Motrin, naproxen) work just as well for pain but hydrocodone makes you care less about the pain. That’s because you will be much more dopey on hydrocodone—oh, and more constipated.
  • Explore other options for postoperative pain.After an operation is a time when most doctors will prescribe you hydrocodone but for some simpler surgeries you may not need it. NSAIDS work just as well most of the time. The use of a single dose of Celebrex (celecoxib) in the treatment of acute postoperative pain found that 33% of patients receiving celecoxib 200 mg, and 44% of patients receiving 400 mg, experienced at least 50% pain relief.Listen to this too: a single dose of ibuprofen was found to provide at least 50% pain relief in approximately half of patients with moderate to severe postoperative pain. An NSAID may be all you need.
  • Low back pain.In most cases, first-line treatment of low back pain (LBP) should consist of an NSAID or acetaminophen. Long term use of NSAIDS is associated with gastrointestinal and kidney risks, so a short course of a low dose NSAID, possibly along with a proton pump inhibitor (omeprazole, etc) to protect your stomach and you should be set.When pain is severe and disabling, guidelines cautiously recommend opioid analgesics like hydrocodone although the risk of addiction or dependence is noted and continued long term use is a bad idea.
  • Arthritis pain/knee and hip pain.Several classes of drugs are recommended by the American College of Rheumatology for osteoarthritis (OA) pain in the hand, knee, and hip. For hip OA, first line therapy is acetaminophen, NSAIDs, tramadol, and steroid injections into the joint. Opioid treatment like hydrocodone is recommended only in cases of knee or hip pain that have not responded to the above listed medications or physical therapy.
  • Headache/migraine.NSAIDS like ibuprofen and naproxen have been found to be effective in the treatment of migraine. Approximately one fourth of people with migraine pain experienced a reduction from severe or moderate pain to no pain within 2 hours of taking a 400 mg dose of ibuprofen.
  • When should you use hydrocodone?Opioids are recommended only for severe pain (a score of at least 7 out of 10), as in a postsurgical setting or other situations in which NSAIDs, acetaminophen, or other treatments provide inadequate pain relief.
  • Why is liberal use of hydrocodone a bad idea?Opioids are associated with serious side effects, including respiratory depression, motor and cognitive impairment, sedation, and the development of tolerance. Long term use of opioids can also result in the development of an increased sensitivity to pain, known as opioid-induced hyperalgesia.
  • Hydrocodone doesn’t work as well at NSAIDS for many types of noncancer pain.This always surprises people because they think hydrocodone is “stronger” and thus better. Most of the time it’s not better.A 2004 meta-analysis of 18 randomized clinical trials of opioids for the treatment of various types of noncancer pain found that the mean reduction in pain intensity was approximately 20% to 30% for arthritis pain, but was approximately 10% for musculoskeletal pain. That’s not great.
  • Why are we using more hydrocodone in the U.S.?No reason. There should be widespread concern that the use of opioids is increasing at an unwarranted and possibly hazardous rate. With the increased use of opioids, there has been an increase in opioid-related overdoses and deaths.CDC data on poisoning deaths indicate that the number of deaths related to opioid use increased nearly 4-fold from 4030 in 1999 to 14,800 in 2008. In 2008, the number of overdose deaths involving the use of opioid pain relievers exceeded the number of deaths caused by heroin and cocaine combined.

Dr O.


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