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64 NSAIDs and opioids
We believe that the systemic use of NSAIDs in pregnant patients is not
associated with favorable risk-to-benefit ratio. Most NSAIDs are FDA
Pregnancy Category C, although the category changes to D toward the end
of pregnancy. Even for topical applications (e.g. corneal abrasion), there
are alternatives, even opioids, that are preferable. The risk of systemic and
fetal effects, including those on the ductus arteriosus, is simply too high
for NSAID administration to gravida. We also believe that, although the
evidence of harm is not irrefutable, NSAIDs are best avoided in breastfeeding
mothers.
NSAIDs (and acetaminophen) will always claim one advantage over
opioids: antipyresis. Given the improvement in comfort that is inevitably
achieved with defervescence, treatment of pain accompanied by fever should
include either an NSAID or acetaminophen.
n Opioids
In reviewing the recommendations and evidence from this text, it is clear
that the opioids remain the most important class for the ED provider dealing
with acute pain of moderate to high severity. Information relevant to the
opioids is presented in the table on p. 402.
For most patients, the potential problems with opioids have little to do
with efficacy in relieving pain. In fact, one of the causes for concern related to
opioids is that these agents relieve pain so effectively that the ED physician
fails to provide nonpharmacologic pain relief (e.g. splinting). More problematic
is the potential that the acute care provider, falsely reassured by opioidmediated
pain relief, prematurely ceases the diagnostic search for the
condition that caused the pain.
Perhaps the lengthy history of opioids’ effectiveness is responsible for the
relatively few rigorous analyses of their risks and benefits – either compared
with each other or compared with non-opioid analgesics. There is abundant
data on opioid use in the ED, however, and some common threads from this
chapter are noteworthy.
First, equipotent doses of pure opioid agonists tend to be equally effective.
There remains potential that an individual patient will respond better to one