The opioid epidemic has created a shift in pain management.

As fatal overdoses from prescription opioids continue to rise,1 the medical community has reacted. From 2011 to 2015, opioid prescriptions declined 11% while prescriptions for nonsteroidal anti-inflammatory drugs (NSAIDs) increased 10%.2

Health care professionals are seeking ways to help provide responsible pain management for their patients in need.

Pain isn’t going away anytime soon, and as prescribers turn to NSAIDs as a possible alternative to opioids, it’s important to recognize the dose-related risks of NSAIDs before prescribing.

Compared to low-medium NSAID doses, high doses have been shown to:

It’s the perfect pharmacotherapeutic storm. The opioid crisis may drive more and more physicians away from opioids toward other alternatives, such as NSAIDs.

—Vijay Sikand, MD
Fellow, American Academy of Family Physicians
Adjunct Assistant Professor of Medicine
Tufts University School of Medicine

Following the recommendations from professional medical organizations may help minimize dose-related risk.6-15

With mounting evidence over the past 10+ years, FDA and professional medical organizations around the world agree that using the lowest effective dosage for the shortest duration is the recommended approach to NSAID use in order to minimize the dose-related risks.6-15

Select an organization to see their recommendation on NSAID dosing.

American College of Cardiology

In all cases, the lowest effective dose should be used for the shortest possible time.7

American Heart Association

In all cases, the lowest effective dose should be used for the shortest possible time.7

American College of Rheumatology

If a patient and provider agree to utilize an NSAID…then the lowest effective dose of the least expensive agent should be considered first line. Low doses of NSAIDs are safer than high doses.8

National Kidney Foundation

Even with normal kidney function, you should use analgesics9:
– Exactly as prescribed or as on the label
– At the lowest dose possible
– For the shortest period of time

American Gastroenterological Association

Risk can be reduced through the use of the lowest effective dose for the shortest duration of time.10

Osteoarthritis Research Society International

NSAIDs should be used at the lowest effective dose but their long-term use should be avoided if possible.11

European Medicines Agency

Use NSAIDs at the lowest effective dose for the shortest possible duration to control symptoms.12

National Institute for Health and Care Excellence

Oral NSAIDs/COX-2 inhibitors should be used at the lowest effective dose for the shortest possible period of time.13

Health Canada

To minimize the potential risk for an adverse event, the lowest effective dose should be used for the shortest possible duration.14

England's National Health Service

Always use the lowest effective dose for the shortest duration possible.15

References:

1. Efforts of the National Institute on Drug Abuse to Prevent and Treat Prescription Drug Abuse: Hearings Before the House Committee on Energy and Commerce Subcommittee on Oversight and Investigations, 113th Cong (2014) (testimony of Nora D. Volkow, MD, director, National Institute on Drug Abuse). 2. IMS National Prescription Audit, Total Prescriptions, 2011-2015. 3. García Rodríguez LA, Tacconelli S, Patrignani P. Role of dose potency in the prediction of risk of myocardial infarction associated with nonsteroidal anti-inflammatory drugs in the general population. J Am Coll Cardiol. 2008;52(20):1628-1236. 4. García Rodríguez LA, Hernández-Díaz S. Relative risk of upper gastrointestinal complications among users of acetaminophen and nonsteroidal anti-inflammatory drugs. Epidemiology. 2001;12(5):570-576. 5. Huerta C, Castellsague J, Varas-Lorenzo C, García Rodríguez LA. Nonsteroidal anti-inflammatory drugs and risk of ARF in the general population. Am J Kidney Dis. 2005;45(3):531-539. 6. US Food and Drug Administration. Public health advisory – FDA announces important changes and additional warnings for COX-2 selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs). http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm150314.htm. Published April 7, 2005. Accessed August 15, 2016. 7. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol. 2007;50(7):e1-e157. 8. American College of Rheumatology Ad Hoc Group on Use of Selective and Nonselective Nonsteroidal Antiinflammatory Drugs. Recommendations for use of selective and nonselective nonsteroidal antiinflammatory drugs: an American College of Rheumatology white paper. Arthritis Rheumatol. 2008;59(8):1058-1073. 9. National Kidney Foundation. Pain medicines (analgesics). https:/www.kidney.org/atoz/content/painMeds_Analgesics. Accessed August 15, 2016. 10. American Gastroenterological Association, Wilcox CM, Allison J, Benzuly K, et al. Consensus development conference on the use of nonsteroidal anti-inflammatory agents, including cyclooxygenase-2 enzyme inhibitors and aspirin. Clin Gastroenterol Hepatol. 2006;4(9):1082-1089. 11. Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16(2):137-162. 12. European Medicines Agency. http://www.ema.europa.eu/docs/en_GB/document_library/Press_release/2009/11/WC500014477.pdf. Published September 26, 2006. Accessed August 15, 2016. 13. National Institute for Health and Care Excellence (UK NICE). http://www.nice.org.uk/CG059. Published February 2008. Accessed August 15, 2016. 14. Health Canada. http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-demande/guide-ld/nsaid-ains/nsaids_ains-eng.php. Published November 23, 2006. Accessed August 15, 2016. 15. National Health Service. http://www.wirral.nhs.uk/document_uploads/Disclosure-Feb2010/776-NSAIDsguidelinesDraftV2Nov09(2).pdf. Published November 23, 2009. Accessed August 15, 2016.