Nonopioid, Multimodal Analgesia as First-line Therapy After Otolaryngology Operations: Primer on Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

John D. Cramer, Michael L. Barnett, Samantha Anne, Brian T. Bateman, Richard M. Rosenfeld, David E. Tunkel, Michael J. Brenner

Research output: Contribution to journalReview articlepeer-review

2 Scopus citations


Objective: To offer pragmatic, evidence-informed advice on nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy after surgery. This companion to the American Academy of Otolaryngology–Head & Neck Surgery (AAO-HNS) clinical practice guideline (CPG), “Opioid Prescribing for Analgesia After Common Otolaryngology Operations,” presents data on potency, bleeding risk, and adverse effects for ibuprofen, naproxen, ketorolac, meloxicam, and celecoxib. Data Sources: National Guidelines Clearinghouse, CMA Infobase, National Library of Guidelines, NICE, SIGN, New Zealand Guidelines Group, Australian National Health and Medical, Research Council, TRIP database, PubMed, Guidelines International Network, Cochrane Library, EMBASE, CINAHL, BIOSIS Previews, ISI Web of Science, AHRQ, and HSTAT. Review Methods: AAO-HNS opioid CPG literature search strategy, supplemented by PubMed/MEDLINE searches on NSAIDs, emphasizing systematic reviews and randomized controlled trials. Conclusion: NSAIDs provide highly effective analgesia for postoperative pain, particularly when combined with acetaminophen. Inconsistent use of nonopioid regimens arises from common misconceptions that NSAIDs are less potent analgesics than opioids and have an unacceptable risk of bleeding. To the contrary, multimodal analgesia (combining 500 mg acetaminophen and 200 mg ibuprofen) is significantly more effective analgesia than opioid regimens (15 mg oxycodone with acetaminophen). Furthermore, selective cyclooxygenase-2 inhibition reliably circumvents antiplatelet effects. Implications for Practice: The combination of NSAIDs and acetaminophen provides more effective postoperative pain control with greater safety than opioid-based regimens. The AAO-HNS opioid prescribing CPG therefore prioritizes multimodal, nonopioid analgesia as first-line therapy, recommending that opioids be reserved for severe or refractory pain. This state-of-the-art review provides strategies for safely incorporating NSAIDs into acute postoperative pain regimens.

Original languageEnglish (US)
Pages (from-to)712-719
Number of pages8
JournalOtolaryngology - Head and Neck Surgery (United States)
Issue number4
StatePublished - Apr 2021


  • NANSAID; ketorolac
  • acetaminophen
  • analgesia
  • bleeding
  • guideline
  • hydrocodone
  • ibuprofen
  • nonsteroidal anti-inflammatory drug
  • opiate
  • opioid
  • otolaryngology
  • oxycodone
  • pain management
  • persistent opioid use
  • postoperative pain
  • surgery
  • tonsillectomy

ASJC Scopus subject areas

  • Surgery
  • Otorhinolaryngology


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