Answer: Balancing the benefits of well-controlled pain with the risks of analgesic use is complicated and often challenging for health care professionals and patients alike. Although there are a number of therapeutic options for the treatment of pain, none are without risk.
Concerns of hepatotoxicity with the use of acetaminophen, overdose and dependence with opioids, and gastrointestinal (GI)-related events with nonsteroidal anti-inflammatory drugs (NSAIDs) force prescribers to critically evaluate the risks and benefits for every patient.
The Food and Drug Administration (FDA) has developed initiatives to improve the safe use of each of these analgesic types; however, the comparative safety of these agents is difficult to determine. Recently, debate has ensued over whether drug-induced mortality is higher with NSAIDs or opioids.
Mortality reported with NSAID use is generally linked to NSAID-associated GI bleeding, and the reported incidence is quite variable
estimates were made using different patient populations at different periods of time and should not be directly compared
All-cause mortality was higher in patients receiving opioids than other analgesics. An overall mortality incidence rate of 48/1,000 person-years was reported for patients taking non-selective NSAIDs compared with 75/1,000 person-years with opioids.
Although this is a more accurate comparison of mortality between opioids and NSAIDs, it is not without limitations
First, despite propensity score matching for a variety of disease states, it is possible that patients receiving opioids were in poorer health than those receiving NSAIDs.
Second, there are some unknown factors including the use of nonprescription pain relievers, the type of NSAID or opioid used, as well as the dose or duration of the analgesic.
In summary, it does not appear that NSAIDs cause more deaths than opioids; however, the evidence is poor.
The comparative safety of NSAIDs and opioids is difficult to assess without a well-designed clinical trial. Since no trial of this scope is likely to be conducted, it is imperative that prescribers consider the patient-specific risks and benefits of each class of medication prior to prescribing. The dramatic increase in opioid-related overdose deaths is worthy of consideration, but should not preclude appropriate prescribing of these agents for patients who require this level of analgesia.