Ibuprofen Works Better Than Opioids for Post-Surgical Pain

Opioids are often prescribed to help with pain after surgery, but a new study suggests they may not always be necessary. In some situations, Advil and other over-the-counter medications might be even better.

The study, which was published in the Canadian Medical Association Journal, conducted a systematic review and meta-analysis of 40 randomized controlled trials of more than 5,100 adults and their pain after surgery. The researchers analyzed pain levels (on a one to 10 scale, with 10 being the highest pain imaginable) and the safety of medications that contain the opioid codeine, like Tylenol #3, when compared with non-steroidal anti-inflammatory drugs (NSAIDs).

The findings were surprising: People who had NSAIDs after surgery reported better pain scores after six hours than those who took codeine. NSAIDs were also linked with better overall health assessments at six hours after surgery and 24 hours later. NSAIDs also caused fewer side effects, including bleeding issues.

The researchers questioned the common use of codeine for post-operative pain in the study. "Codeine use is widespread in this setting and codeine remains the most commonly prescribed opioid in many countries," they wrote. "However, its efficacy is variable, its potency is low and its use is associated with risks of severe adverse effects and misuse."

The researchers also had this to say: “Postoperative pain can be effectively managed with NSAIDs, and NSAIDs have been shown to reduce opioid consumption in postoperative patients.” In the conclusion, the researchers wrote that the findings “strengthen existing evidence” for the use of NSAIDs over codeine for post-op pain, adding: “Further studies should assess the comparative effectiveness of other nonopioid analgesics, and test these findings in other populations and settings.”

Opioid Basics

Opioids are a class of drugs that include prescription pain relievers like oxycodone (OxyContin), hydrocodone (Vicodin), codeine, and morphine, along with illegal drugs like heroin, and synthetic opioids like fentanyl.

Opioids interact with opioid receptors on nerve cells in the body and the brain. Opioid pain relievers are designed to be taken for a short period of time and as prescribed by a doctor, but they can be abused. Regular use, even with a prescription, can lead to dependence, addiction, overdoses, and deaths.

NSAID Basics

NSAIDs come in different strengths and formulas, and include over-the-counter medications like aspirin and ibuprofen. They prevent an enzyme called cyclooxygenase from doing its job.

“NSAIDs work by blocking key pain-signaling molecules,” Jamie Alan, PharmD, PhD, assistant professor of pharmacology and toxicology at Michigan State University, tells Verywell Health. “The key with NSAIDs and acetaminophen is to use the medications ‘around the clock.’ This means you don't take the medicine when you feel the pain, but you keep on top of the pain by taking these medications on a scheduled basis.”

NSAIDs work to relieve pain, reduce inflammation, lower fevers, and help prevent blood from clotting.

The Findings Come As the U.S. is in the Middle of an Opioid Crisis

The U.S. has been grappling with an opioid epidemic for years, and data show that the problem continues to get worse. The number of drug overdose deaths increased by almost 5% from 2018 to 2019, and has quadrupled since 1999.

More than 70% of the 70,630 drug overdose deaths in 2019 involved an opioid. There were also significant increases in opioid-related drug overdose deaths from 2018 to 2019, including a 6% increase in opioid-involved death rates, 7% increase in prescription opioid-involved death rates, 6% increase in heroin-involved death rates, and 15% increase in synthetic opioid-involved death rates.

The Centers for Disease Control and Prevention (CDC) has identified three waves of opioid overdose deaths:

• Wave 1: This began with increased prescribing of opioids in the 1990s, with overdose deaths involving prescription opioids increasing since at least 1999.
• Wave 2: This wave began in 2010, with increases in overdose deaths involving heroin.
• Wave 3: The third wave started in 2013, with increases in overdose deaths due to synthetic opioids, especially illegally-made fentanyl.

As a result, the CDC has launched an initiative to improve prescription drug monitoring programs, increase public awareness about prescription opioid misuse and overdose, and give healthcare providers tools and guidance for evidence-based decision-making to improve opioid prescribing and safety for patients.

Effective, But Not in Every Case

Alan says that the study’s findings are "not surprising."

"There have been several studies showing that using ibuprofen—or other NSAIDs—with or without acetaminophen can be equal or better at pain management compared to opioids," she says. "These medications do not carry a risk of addiction or dependence."

But Medhat Mikhael, MD, a pain management specialist and medical director of the non-operative program at the Spine Health Center at MemorialCare Orange Coast Medical Center in Fountain Valley, California, tells Verywell Health that it’s difficult to apply the findings to all post-operative pain relief. The study didn’t specify the type of surgeries the patients who reported lower levels of pain had, and that matters, he says.

"If we’re talking about minor surgery then, yes, NSAIDs can do a better job than opioids," he says. "But it has its limits. NSAIDs are not likely to help with someone who had their chest open during surgery."

Mikhael points out that NSAIDs also aren’t ideal when a patient has kidney disease, given that they can worsen kidney function or bleeding. But, he adds, "It can be good enough for a healthy person to use for a day or two after minor surgery."

Alan says that a growing number of doctors are prescribing NSAIDs for post-operative pain. "These medications are pretty effective at managing post-op pain," she says. "Don't be surprised if your healthcare provider places you on this type of regimen instead of an opioid. The key is to take these as prescribed, and don't skip doses. You might be pretty surprised at how well they work."