Numerous studies have shown that opiates are not needed for many types of surgery.  Indeed, I have not seen solid evidence that opiates are needed for any type of surgery, at least not for pain relief or shivering.  Some studies have found them slightly better for pain relief, but others have found no difference or even found the opiates inferior.  Why anyone would want to prime the nervous system for an addiction to the most addictive drugs known to the human race is beyond me.  It's just out-dated and dangerous physician folklore.  For dental surgery, click on the above.  For others, see below.  

In the human studies below covering 7,278 patients where a narcotic is compared to a non-narcotic, in 21 the non-narcotic was better, in 7 the non-narcotic did as well with fewer side-effect, in 15 they were equal, and in only one was the narcotic better, i.e. against acetaminophen.  Thus, for this group, the narcotics track record is 1 win, 30 losses and 18 ties, with the only win against the weakest team in the league.  Narcotics are losers.  Another five studies found no add-on benefit to narcotics.

For dental surgery, narcotics are 0 wins, 29 losses, and 2 ties.

For child surgery, narcotics are 0 wins, 12 losses, and 7 ties.

For knee surgery, narcotics are 0 wins, 8 losses, and 2 ties.

For all surgeries added together, narcotics are 1 win, 72 losses, and 29 ties (107 studies).

Abdominal Surgery: Hydrocodone/Ibuprofen Helped Only 25% More Patients than Ibuprofen Alone: In a 6-hour DB PC study of 120 patients after abdominal surgery with moderate to severe postop pain, the combination of 15 mg hydrocodone bitartrate with 400 mg ibuprofen was significantly superior to ibuprofen alone for all hourly analgesic evaluations, weighted sum of pain intensity differences (SPID), total pain relief (TOTPAR), and global rating of study medication. No patients in the hydrocodone with ibuprofen group required analgesic remedication during the 6-hour study period, compared with 25% with ibuprofen and 82% with placebo. Analgesic efficacy of a hydrocodone with ibuprofen combination compared with ibuprofen alone for the treatment of acute postoperative pain. Sunshine A, et al. NYU Medical Center. J Clin Pharmacol. 1997 Oct;37(10):908-15. Ed: Three quarters of hydrocodone patients appear to have been needlessly given a powerfully addictive narcotic.  Ibuprofen 400 mg by itself worked well for 75% of all patients and the amount of pain relieved in the other 25% appears minor and might have been relieved with a non-narcotic rescue medication.  This is not a win for narcotics, because hydrocodone is being compared to a placebo in this study.  Also, the study may have been funded by the manufacturer.

Abdominal or Pelvic: Ibuprofen Much Better than Oxycodone; Oxycodone Adds Only Modest Extra Effect:  In a 6-hour DB PC study of 456 women 14-48 hours after abdominal or pelvic surgery and suffering from moderate to severe pain, a single-dose combination tablet containing oxycodone 5 mg/ibuprofen 400 mg was compared to either agent alone and to placebo. Combination treatment was associated with significantly better total pain and pain intensity scores compared with ibuprofen alone (P < 0.02 and P < 0.015), oxycodone alone (P < 0.009 and P < 0.001), or placebo (both, P < 0.001). Patients' global ratings of analgesic efficacy were significantly higher in the combination-treatment was slightly better than ibuprofen (P < 0.044) and much better than oxycodone alone or placebo (both P < 0.001). Combination oxycodone 5 mg/ibuprofen 400 mg for the treatment of pain after abdominal or pelvic surgery in women: a randomized, double-blind, placebo- and active-controlled parallel-group study. Singla N, et al. Huntington Memorial Hospital, Pasadena, California. . Clin Ther. 2005 Jan;27(1):45-57. Ed: Two of the 3 authors are employees of the manufacturer and the first author was paid by a grant from the manufacturer. Pain relief in the ibuprofen group could easily have been increased by the addition of caffeine, by the addition of acetaminophen, or by increasing the dose of ibuprofen. Besides each of these proven techniques, many more are available.  There is absolutely no need to push highly addictive narcotics with minor pain relief benefits. While the study is a good design, the conclusions are highly irresponsible and corrupt.  Manfacturers, especially of highly addictive narcotics, should not be allowed to be co-researchers or have any influence of the study design or its publication. 

Abdominal Surgery: Ketorolac Decreased Morphine Usage by 82%: In a DB study of 191 patients with at least moderate pain after major abdominal surgery, patients received ketorolac by patient-controlled analgesia (PCA) bolus alone (Ket B), ketorolac by bolus plus infusion (Ket I), or morphine by PCA bolus (morphine), with injectable morphine available for supplementation. Supplemental morphine was requested by 71% of Ket B patients, 67% of Ket I patients, and 38% of morphine patients (p < or = 0.001 for Ket B vs morphine). Although patients receiving ketorolac were given more supplemental morphine than the morphine group (6.0 mg Ket I, 6.2 mg Ket B, 4.0 mg morphine), there was a large morphine-sparing effect in both ketorolac groups (total morphine 6.0 mg Ket I, 6.2 mg Ket B, 33.3 mg morphine). Overall pain relief scores were similar for morphine and Ket I groups, and were lower for Ket B than for morphine (p = 0.002). Evaluation of the safety and efficacy of ketorolac versus morphine by patient-controlled analgesia for postoperative pain. O'Hara DA, et al. Robert Wood Johnson Medical School, New Brunswick, New Jersey. Pharmacotherapy. 1997 Sep-Oct;17(5):891-9. Ed: This is a poorly designed study since the comparison between ketorolac and morphine is obscured by the PRN morphine.  While it showed that ketorolac dramatically decreased morphine usage, it doesn't show what the effects of no morphine at all would have been and how morphine compares to ketorolac by itself. The total amount of extra PRN morphine usage by the ketorolac patients was a miniscule 2.1 mg. It could well be that the extra morphine wasn't helpful at all for pain, but served merely as a marker for pain or that morphine patients were too sedated to complain about pain, or that some morphine patients had too much nausea to want another dose of the pain medicine that was giving them the nausea.  In any case, the maximum benefits of morphine were slight and not enough to justify priming people for opiate addiction.

Abdominal and Thoracic Post-Op Pain: IV Propacetamol(Acetaminophen) as Good as IM Meperidine: In a DB study of 40 patients with moderate to severe thoracic or abdominal post-op pain,  2 g propacetamol in 100 ml normal saline IV did as well as meperidine 50 mg IM for post-op analgesia. Pain was evaluated 10 times with visual analog scale and verbal describing scale during 6 h from the beginning of propacetamol infusion. A randomized, double blind, and controlled clinical trial of the non-addictive propacetamol in postoperative analgesia. Ma EL, et al. PUMC Hospital, Beijing, China. . Zhong Guo Yi Xue Ke Xue Yuan Xue Bao 2003 Jun;25(3):329-32.

Abdominal: Ketorolac Did as Well as Meperidine: In a DB PC study of 129 patients after major abdominal surgery, during the first 2 h, meperidine 100 mg had a more rapid onset of action than ketorolac or placebo. Thereafter 100 mg pethidine and 30 mg ketorolac were equally effective. 30 mg ketorolac had a similar efficacy to 100 mg meperidine over the 8-h study period and 10 mg ketorolac being slightly less effective than 30 mg ketorolac. Placebo-controlled comparison of single intramuscular doses of ketorolac tromethamine and pethidine for post-operative analgesia. Folsland B, et al. Ulleval Hospital, Oslo, Norway. J Int Med Res 1990 Jul-Aug;18(4):305-14.

Abdominal Hystectomy: IM Diclofenac Longer Pain Relief with Less Bowel Paralysis than Meperidine: In a DB PC study of 63 patients with moderate to severe pain after an abdominal hystectomy, diclofenac IM gave significantly longer pain relief than meperidine or placebo. Few side-effects were reported after diclofenac and post-operative bowel paralysis tended to be shorter than with meperidine. Diclofenac versus pethidine in the treatment of pain after hysterectomy. Carlborg L, et al. Lanssjukhuset, Halmstad, Sweden. Eur J Anesth 1987 Jul;4(4):241-7.

Abdominal Gynecologic: Oxycodone/Acetominophen Not as Good as Bromfenac But More Side-Effect: In a DB PC study of 238 women with pain due to abdominal gynecologic surgery, they received single oral doses of bromfenac (50 or 100 mg), acetaminophen 650 mg/oxycodone 10 mg, ibuprofen 400 mg, or placebo. Then, in the multiple-dose phase, 204 patients received bromfenac, acetaminophen/oxycodone, or ibuprofen for up to 5 days. In the single-dose phase, both bromfenac doses produced peak pain relief equivalent to acetaminophen/oxycodone, but the responses to bromfenac were longer lasting. Bromfenac produced significantly better overall (8-hour) analgesic summed scores than acetaminophen/oxycodone. Ibuprofen was less efficacious than the other analgesics. The remedication rate was lower in both bromfenac groups than in the other treatment groups. The acetaminophen/oxycodone group reported more somnolence and vomiting. Bromfenac sodium, acetaminophen/oxycodone, ibuprofen, and placebo for relief of postoperative pain. Johnson GH, et al. Latter Day Saints Hospital, Salt Lake City. Clin Ther. 1997 May-Jun;19(3):507-19.

C-Sections: Indomethacin Suppositories Means No Need for Opiates: In a DB PC study of 30 women with spinal anaesthesia for elective caesarean in a standard manner using hyperbaric bupivacaine, fentanyl and morphine, two rectal suppositories, followed by 12-hourly suppositories for six doses (three days) of 100 mg indomethacin found median time to first analgesia (TTFA) was 9 hours for the placebo group v. 39.5 hours for indomethacin (P < 0.003). Additional analgesic requests throughout the postoperative period were less in women who received indomethacin: 4 v 11 (P < 0.001). Women who received indomethacin had dramatically less pain on the first postoperative day, especially on movement: mean VAS 1.4 v 5.1 (P < 0.00001). There were no reported adverse neonatal or maternal effects from the use of indomethacin. Rectal indomethacin potentiates spinal morphine analgesia after caesarean delivery. Pavy TJ, et al. University of British Columbia, Vancouver, Canada. Anaesth Intensive Care. 1995 Oct;23(5):555-9.

C-Section: Severe Pain Treated at Least as Well with Ketoprofen (Orudis) as with Oxycodone/Acetaminophen with Fewer Side-Effects and No Addiction Risk: In a DB PC study of 240 women with severe postop pain after C-section, single doses of 100 mg or 50 mg ketoprofen, the combination of 650 mg acetaminophen plus 10 mg oxycodone hydrochloride, 650 mg acetaminophen, or placebo found both ketoprofen doses superior to acetaminophen and placebo, the 100 mg dose better than the 50 mg, and ketoprofen 100 mg at least as good as the narcotic with its effect lasting longer although not quite as strong during the first hour. There were more side-effects with the narcotic. The study was continued for 7 days comparing ketoprofen 100 mg or 50 mg or oxycodone 5mg/acetominophen 325 mg as needed. Fewer doses of the ketoprofen were needed.   Ketoprofen, acetaminophen plus oxycodone, and acetaminophen in the relief of postoperative pain. Sunshine A, et al. New York University Medical Center. Clin Pharmacol Ther. 1993 Nov;54(5):546-55.

C-Section: Ketorolac Did as Well as Meperidine with Fewer Side-Effects: In a DB study of 100 women undergoing elective C-sections, IM ketorolac 30 mg and IM meperidine 75 mg in the recovery ward up to every 6 hours found no difference in the duration of analgesia. Pain VAS and overall assessment of analgesia was similar between groups, although more side-effects (nausea, dizziness) were noted in the meperidine. Analgesia after caesarean section with intramuscular ketorolac or pethidine. Gin T, et al. Chinese University of Hong Kong. Anesth Intensive Care 1993 Aug;21(4):420-3.

C-Section and Orthopedic: Indoprofen IV as Good as Meperidine: In a DB study of 40 C-section patients and 40 orthopedic surgery patients, Indoprofen (400 mg) IV did as well for pain as meperidine (1,5 mg/kg). Indoprofen--a new non-opioid analgesic. A comparison with pethidine. Brock-Utne JG, et al. S Afr Med J 1985 Nov 23;68(11):803-4.

Cholescystectomy: Oxycodone No Better than Paracetamol (Acetominophen): In a DB study of 20 women undergoing a cholecystectomy for gallstones, either 10 mg oxycodone, or 1000 mg paracetamol was given orally. Oxycodone resulted in more pre-operative sedation. Post-operative pain was not significantly different by patient report or by a visual analog. No significant differences were noted for side effects or canalization. Oxycodone versus paracetamol in oral premedication in cholecystectomy. Speranza R, et al. Ospedale Bassini, Milan, Italy. Minerva Anestesiol. 1992 Apr;58(4):191-4.

Cholescystectomy Post-Op Pain: NSAID Floctafenine Better than Propoxyphene But Not as Effective as Meperidine: In a DB crossover study of 40 patients, the non-narcotic floctafenine 200 mg did not do as well as meperidine 75 mg but did better than propoxyphene 65 mg. However, side-effects were fewest after floctafenine. Morris ME, et al. Clin Pharmacol Ther 1978;23:383-9.

Epidurals: Arthroscopic: Fentanyl Epidural Improves Speed of Sensory/Motor Block by Only 4-5 Minutes with More Side-Effects: In a DB study of 45 young adults undergoing knee arthroscopic surgery, those given 100 mcg epidural fentanyl with their epidural 15 mL of 1% ropivacaine had slightly faster onset of sensory block compared to 100 mcg of IV fentanyl or normal saline control (13 min. vs. 16 min, vs. 17.7 min, p<.05) at T10. The onset times of motor block were also a little faster (12 and 24 min) vs. IV fentanyl (17 and 31 min, P < 0.05) or Control (18 and 33 min, P < 0.05). There was no difference in the incidence of shivering among the three groups. Pruritus occurred 20% with epidure and 7% with IV fentanyl. Onset of sensory and motor blocks during epidural ropivacaine anesthesia without significant fentanyl-related side effects. Epidural fentanyl speeds the onset of sensory and motor blocks during epidural ropivacaine anesthesia. Cherng CH, et al. Tri-Service General Hospital, Taipei, Taiwan. . Anest Analg 2005 Dec;101(6):1834-7. Ed: Exposing another human being to the addictive risk of a powerful dose of narcotics in order to save 4-5 minutes is wrong.  Fentanyl has no place in epidural anesthesia. Also, fentanyl here is being compared to a placebo and a non-narcotic comparator may have done as well or better.

Epidurals: C-Sections: Sufentanil Did Add Pain Relief to Ropivacaine Alone But Pain Only Mild with Ropivacaine Alone: In a DB study of 60 women undergoing C-sections, 120 mg ropivacaine 1%, or 120 mg ropivacaine plus 10 microg or 20 microg sufentanil was injected with additional epidural ropivacaine if necessary. The onset time for the sensory block was not significantly different among the groups. Also, VAS scores at delivery did not differ significantly between the plain ropivacaine 1% group (18 mm), the 10-microg sufentanil group (1 mm), and the 20-microg sufentanil group (6 mm). The total dose of ropivacaine was slightly higher in the plain ropivacaine 1% group (145 mg) compared to the patients receiving additional 10 microg sufentanil (130 mg, P = 0.02) or 20 microg sufentanil (129  mg, P = 0.01). The incidence of maternal side-effects and neonatal outcome were similar in all groups. Ropivacaine 1% alone provided sufficient analgesia. Sufentanil addition did not significantly improve the quality of epidural anaesthesia with ropivacaine 1.0% for Caesarean section. Epidural ropivacaine 1% with and without sufentanil addition for Caesarean section. Bachmann-Mennenga B, et al. Klinikum Minden, Germany. . Acta Anesthes Scand 2005 Apr;49(4):525-31. Ed: In this study, pain with ropivacaine alone was quite mild.  If rescue medication was needed, it could be easily provided by a non-narcotic medication.

Epidural in Labor: Fentanyl Not Needed, Harms Newborn, Reduces Successful Breastfeeding: In a DB study of 177 women who previously breast-fed a child and who requested labor epidural analgesia, the children of those in the no fentanyl group did non-significantly better than the intermediate-dose fentanyl group (intent to administer between 1 and 150 mug epidural fentanyl) and significantly better than the high-dose epidural fentanyl group (intent to administer > 150 mug epidural fentanyl). Mothers is the high-dose fentanyl reported more difficulty breast-feeding (21%) than women who were randomly assigned to receive an intermediate fentanyl dose (10%), or no fentanyl (10%)(P = 0.09). Neurobehavior scores were lowest in the infants of women who were randomly assigned to receive more than 150 mug fentanyl (P = 0.03). At 6 weeks postpartum, more high-dose epidural fentanyl women were not breast-feeding (17%) than women who were randomly assigned to receive either an intermediate fentanyl dose (5%) or no fentanyl (2%) (P = 0.005). Effect of Labor Epidural Analgesia with and without Fentanyl on Infant Breast-feeding: A Prospective, Randomized, Double-blind Study. Beilin Y, et al. Anesthesiol 2005 Dec;103(6):1211-1217.

Epidural Thoracic Analgesia: Fentanyl No Better Pain Relief than Added Bupivacaine: In a DB study of 24 patients after major abdominal surgery, adding fentanyl 50 mcg or bupivacaine 50 mg or fentanyl 50 with bupivacaine 25 or 12.5 made no difference with pain relief with bupivacaine being very slightly better. However, mean arterial pressure did decrease more with the bupivacaine. Torda TA, et al. Sydney Australia. Br J Anaesth 1995;74:35-40.

Epidural Thoracic Analgesia: Bupivacaine with Isoflurane did as Well as Conventional Anesthesia with Isoflurane and IV Fentanyl: In a DB study of 30 patients undergoing thoracotomy, there was no significant difference in pain relief, although there was a non-significant trend favoring fentanyl. Aguilar JL, et al. Barcelona. Rev Esp Anest Reanim 1994;41:278-81.

Epidural Thoracic Analgesia: Sufentanil No Better than Bupivacaine with Adrenaline: In a DB study of 30 patients undergoing lateral thoracotomy, there was no difference in pain relief between sufentanil 50 mcg and bupivacaine 0.5% with adrenaline 5 mcg/ml (dose 40 mg) although both were superior to placebo. Supplemental fentanyl was given to 4 of the fentanyl vs. 1 of the bupivacaine patients. Hypotensive episodes occurred in 50% of sufentanyl and 100% of bupivacaine patients. Haak-van der Lely F, et  al. Anesthesia 1994;49:116-8.

Epidural Thoracic Analgesia: Fentanyl No Added Value to Ropivacaine Alone: In a DB study of 30 women undergoing abdominal surgery for gynecologic tumors, ropivacaine 0.375% did as well at suppressing pain as pupivacaine 0.125% with sufentanil. Side-effects were similar. Gottschalk A, et al. Reg Anesth Pain Med 2002;27:367-73. A lower dose of ropivacaine 0.2% did not do as well. Anesth Analg 2002;95:1344-50 and Anesth Analg 2001;93:1587-92, although it was as effective for everything except pain on mobilization in Anasth Intensiv Notfallmed 2001;36:219-23. Tenoxicam can also improve pain relief in TEA with bupivacaine. Anaesth Intensive Care 2002;30:160-6. Epinephrine can as well. Anesth Analg 2002;94:1598-605. TEA with bupivacaine and isoflurane did better than IV anesthesia with propofol and fentanyl. Aesth Analg 2001;92:848-54.

Epidural: Total Gastrectomy: Fentanyl No Better Pain Relief than Ketamine, But More Low Blood Pressure: Beograd. Acto Chir Iugosl 1999;46(1-2):47-52  

Epidural: Fentanyl Narcotic Added No Benefit to Bupivacaine Alone in Coronary Bypass Surgery: In a DB study of 60 patients undergoing off-pump coronary artery bypass grafting, thoracic epidural anesthesia with bupivacaine 0.125% alone, did just as well as bupivacaine 0.125% with fentanyl 3 microg/ml or bupivacaine 0.125% with clonidine 0.6 microg/ml. Pain control was very good and was not significantly different between the groups using similar infusion rates after surgery. Paraesthesia in dermatomes T1 or C8 occurred equally in all three groups. There was no neurological complication related to TEA in this study. Comparison of three different epidural solutions in off-pump cardiac surgery: pilot study. Olivier JF, et al. l'Universite de Montreal, Canada. Br J Anaesth 2005 Nov;95(5):685-91.

Episiotomy Pain: Ibuprofen as Good as Acetaminophen with Codeine with Fewer Side-Effects and Lower Cost: In a DB study of 237 women who gave birth vaginally with episiotomy or a third- or fourth-degree tear, ibuprofen (400 mg) did as well at pain relief during the first 24 hours as acetaminophen (600 mg) with codeine (60 mg) and caffeine (15 mg) (Tylenol No. 3)(3.4 and 3.3 cm on a 10 cm VAS, mean number of doses in 24 hours 3.4 and 3.3, and proportion of treatment failures 14% and 16% respectively). Significantly fewer subjects in the ibuprofen group than in the acetaminophen with codeine group experienced side effects (52% v. 72%) (p = 0.006). Overall, 78% of the treatment failures were in women with forceps-assisted deliveries. Ibuprofen is the preferred choice because it is less expensive and requires less nursing time to dispense. Ibuprofen versus acetaminophen with codeine for the relief of perineal pain after childbirth: a randomized controlled trial. Peter EA, et al. University of British Columbia, Vancouver. CMAJ. 2001 Oct 30;165(9):1203-9.

Episiotomy Pain: Acetaminophen with Codeine no Better than an NSAID: In a DB study of 131 women with episiotomy pain, Lysine Clonixinate 125 mg Q6hr (LC)(an NSAID) did as well as acetaminophen 500 mg+Codeine 30 mg 6 qh during 24 hours. Intensity of spontaneous pain was reduced in 24 hours from 4.28 to 1.73 (P < 0.0001) in the LC group and from 4.78 to 1.90 in the AC-treated group (p < 0.0001). 54% with LC and 55% AC showed onset of analgesic action 30 minutes following dose administration. 95% of LC-treated patients and 96% of PC showed total or partial pain relief during the first treatment day. No sleep disturbances were seen during the night in 75% of patients. Lysine clonixinate vs. paracetamol/codeine in postepisiotomy pain. De los Santos AR, et al. Universidad de Buenos Aires, Argentina. Acta Physiol Pharmacol Ther Latinoam. 1998;48(1):52-8.

Episiotomy Pain: NSAID Nefopam Provided Better Pain Relief than Narcotic Propoxyphene: In a DB PC study of 100 postpartum women with moderate to severe pain, nefopan 45 mg and nefopam 90 mg both resulted in significantly better pain reduction: greater than 50% reduction: nefopam 45 mg 84%, nefopam 90 mg 80%, propoxyphene 65 mg 72%, and placebo 44%.  Bloomfield SS, et al. Clin Pharmacol Ther 1980;27:502-7.

Episiotomy Pain: Neither Diflunisal Nor Propoxyphene/Acetaminophen Helped: In a DB study of 57 women, neither diflunisal 500 mg twice daily nor dextropropoxyphene 65 mg/acetaminophen 650 mg 3 times a day did any better relieving pain over the 2 day study than placebo for pain relief by patient report. Buck ME, et al. Curr Med Res Opin 1978;5:548-9.

Foot Surgery: Flurbiprofen Better Than Acetaminophen with Codeine: In a 24-hour DB study of 83 patients receiving outpatient surgery, flurbiprofen 50 mg. did significantly better than acetaminophen 300 mg. plus codeine phosphate 30 mg for both relief of pain and pain intensity. The efficacy of ANSAID (flurbiprofen) as an analgesic in foot surgery. Soulier SM, et al. Upjohn Company, Kalamazoo, MI. J Foot Ankle Surg. 1997 Nov-Dec;36(6):414-7. Ed: Cost of flurbiprofen is 75 cents for a 100 mg. tablet which can be broken in half. The 50 mg. tabs are no cheaper, but you get half as much. 

General Surgery: Oxycodone Very Slightly Better than Diclofenac (Voltaren) for Post-Surgical Pain, But More Shots and Four Times the Side-Effects: In a DB study of 85 patients after various operations, patients requesting an analgesic were given either 75 mg of diclofenac or 10 mg of oxycodone as an intramuscular injection. The onset of analgesic effect averaged 13 min with oxycodone vs. 16 min with diclofenac. The analgesic effect of diclofenac was slightly weaker than that of oxycodone (on a pain scale of 1-4, 1.6/2.1 after 0.5 h and 1.5/1.8 after 1 h). The patients again asked for an analgesic after an average of 4.6 h in the oxycodone group vs. 6.1 h in the diclofenac group. The average number of injections requested until the first postoperative morning was 2.5 in the oxycodone group and 1.8 in the diclofenac group. Side-effects: 21 patients in the oxycodone group reported a total of 39 side-effects and eight patients in the diclofenac group a total of 10 side-effects. Diclofenac and oxycodone in treatment of postoperative pain: a double-blind trial. Nuutinen LS, et al. Acta Anaesthesiol Scand. 1986 Nov;30(8):620-4. Ed: This study is double-blind but is of lower quality than most.  Of course, it is a much older study. In view of all of the side-effects, I'll rate this study as a tie.

General: Lysine Acetylsalicylate as Good as Meperidine: In a DB study of general surgery patients, twice the customary dose of lysine acetylsalicylate did as well as meperidine in subjective and objective pain relief and performed very well overall with respect to other parameters. Treatment of postoperative pain with non-narcotic drugs; evaluation of lysine acetylsalicylate in high doses. Double-blind controlled study. Pagni E, et al. Minerva Anesth 1981 May;47(5):215-20.

Hemorrhoid Surgery: Post-Op Pain: NSAID Diflunisal Somewhat Better than Narcotic Dextropropoxyphene: In a DB study of 43 patients having excision of hemorrhoids under spinal anesthesia, 25% of patients had no significant pain and did not need any medication. Of the remaining 32, 41% of diflunisal vs. 60% of dextropropoxyphene patients needed additional pain meds. Diflunisal maintained its advantage on the day after surgery, although neither group needed additional meds. Jalovaara P, et al. Ann Chir Gynecol 1985;74:228-32. 

Hip Replacement: Diclofenac Less Pain than Meperidine and Fewer Side-Effects: In a DB PC study of 68 patients the day after hip replacement for arthrosis, an IM injection of diclofenac 75 mg resulted in less pain and fewer side-effects than IM meperidine 50 mg, or placebo (a second injection was usually given after 3.5 h). Pain was recorded before and for 3 h after these injections. Diclofenac for pain after hip surgery. Lingren U, et al. Acta Orthop Scand 1985 Feb;56(1):28-31.

Hip Arthroplasty: Ibuprofen as Good as Ibuprofen plus Codeine: In a DB PC study of 123 hip arthroplasty operations, all received oral diazepam as premedication and spinal anaesthesia with bupivacaine 5 mg/ml 3-4 ml. Postoperatively, when the spinal anaesthesia started to wear off, ibuprofen 800 mg. did as well as ibuprofin with codeine 60 mg and better than placebo (P < 0.05) after 2 and 4 hours, but not after 1, 3 and 5 hours. The placebo group also received 45% more opioids (P < 0.001) compared with the two other groups during the same period. No significant differences in bleeding or side-effects were observed. Prophylactic oral ibuprofen or ibuprofen-codeine versus placebo for postoperative pain after primary hip arthroplasty. Dahl V, et al. Martina Hansens Hospital, Sandvika, Norway. Acta Anaesthesiol Scand. 1995 Apr;39(3):323-6. Ed: There is absolutely no evidence that opiates are needed for "rescue pain." Acetaminophen would probably have done just as well.  Of course, some NSAIDs look better than ibuprofen, at least for acute pain.

Hysterectomy Surgery: Parecoxib and Ketorolac Better than Morphine 4 mg.: In a randomized DB study of 208 women after surgical hysterectomy comparing single-dose intravenous placebo, parecoxib sodium 20 mg or 40 mg, ketorolac 30 mg, or morphine 4 mg followed by multiple-dose parecoxib sodium or ketorolac as needed, single-dose parecoxib sodium 40 mg provided significantly better pain responses to placebo or morphine 4 mg and was comparable to ketorolac 30 mg. Multiple-dose parecoxib sodium 20 mg, 4 times daily, or 40 mg, twice daily, was comparable to ketorolac 30 mg, 4 times daily. A clinical trial demonstrates the analgesic activity of intravenous parecoxib sodium compared with ketorolac or morphine after gynecologic surgery with laparotomy. Bikhazi GB, Snabes MC, Bajwa ZH, Davis DJ, LeComte D, Traylor L, Hubbard RC. University of Miami. Am J Obstet Gynecol. 2004 Oct;191(4):1183-91.

Hysterectomy: Epidural Block in Radical Hystectomy: Morphine Not of Value as Addition to Bupivacaine: In a DB study of 40 patients having radical hysterectomy and pelvic lymphadenectomy with post-op epidural blocks, the addition of morphine to postoperative epidural bupivacaine had only limited effect on pain relief and increases time to normalization of gastrointestinal function. Effect of epidural bupivacaine vs combined epidural bupivacaine and morphine on gastrointestinal function and pain after major gynaecological surgery. Jorgensen H, et al. Herlev University Hospital, Copenhagen County, Denmark. Br J Anaesth. 2001 Nov;87(5):727-32.

Hysterectomy and Cholescystectomy: Ketorolac as Good as Meperidine for Pain and Better for Outcome: In a DB study of 210 adults after abdominal hysterectomy or cholescystectomy, IM ketorolac 30 mg every 3-6 hours as needed then 10 mg every 4-6 hours resulted in higher functioning during the first 3 days post-op when compared to IM meperidine 100 mg every 3-6 hours then acetaminophen with codeine (600/60). Patients receiving ketorolac had lower nursing utilization scores, too. Times to first bowel movement, walking without assistance, and first oral fluids were significantly shorter after ketorolac than meperidine. Mean pain intensity scores and pain relief were comparable between ketorolac and meperidine. Comparison of ketorolac and meperidine in patients with postoperative pain--impact on health care utilization. Stahlgren LR, et al. St. Joseph's Hospital, Denver, Colorado. Clin Ther 1993 May-Jun;15(3):571-80; discussion 570.

Hysterectomy via Laparotomy: Morphine Inferior to Both IM Parecoxib and to IM Ketorolac: In a DB PC study of 202 women experiencing moderate-to-severe pain on the first day after laparotomy abdominal hysterectomy or myomectomy, IM parecoxib 20-40 mg, a COX-2-specific inhibitor, and IM ketorolac 30 mg. both did much better than IV morphine 4 mg or placebo for most measures of analgesic efficacy at most time points, including a 2-3 fold longer time to rescue analgesia (P </= 0.05). All treatments were well tolerated. Efficacy and safety of intravenous parecoxib sodium in relieving acute postoperative pain following gynecologic laparotomy surgery. Barton SF, et al. Columbia St. Mark's Hospital, Salt Lake City. Anesthesiology. 2002 Aug;97(2):306-14.

Hysterectomy Post-Op Pain: NSAID Fluproquazone Better than Narcotic Propoxyphene/Acetaminophen: In a DB study of post-hysterectomy patients, fluproquazone 200 mg relieved pain better both with the first dose and over the first 24 hours vs. propoxyphene 65 mg/aceminophen 500 mg or placebo. Side-effects were equally well tolerated. Frerich D, et al. Arzneimittleforschung 1981;31:925-7.

Induction with Propofol Better with Ketamine than Fentanyl: In a DB PC study of 90 adults undergoing surgery, ketamine 0.5 mg/kg before induction with propofol improved the hemodynamic profile better than fentanyl 1 mcg/kg with less prolonged apnea and had and better laryngeal mask airway insertion conditions than normal saline. Randomized double-blind comparison of ketamine-propofol, fentanyl-propofol and propofol-saline on haemodynamics and laryngeal mask airway insertion conditions. Goh PK, et al. University Malaya Medical Centre, Kuala Lumpur, Malaysia. Anesthes Intensive Care 2005 Apr;33(2):223-8.

Injection Pain of Diazepam: Relieved Much Better by Ketamine Than by Fentanyl: In a DB study of 150 patients undergoing IV diazepam injections as part of surgery, ketamine 10 mg did much better than fentanyl in reducing the pain of diazepam injection (p < 0.001). The effect of ketamine and fentanyl in reducing the pain of diazepam injection. Khosravi MB, et al. Shiraz University, Iran. . Middle East J Anesth 2004 Oct;17(6):1093-8.

Injection Pain of Propofol: Lidocaine Better than Fentanyl or Morphine and as Good as Meperidine with Fewer Side-Effects: In a DB PC study comparing I.V. pretreatment with fentanyl 150 microg, morphine 4 mg, meperidine 40 mg, 2% lidocaine 3 mL or placebo in reducing propofol injection pain in 175 patients, lidocaine and meperidine significantly reduced propofol injection pain more than placebo (P < 0.05), but there were more side effects in the meperidine group. Fentanyl and morphine reduced the intensity of propofol injection pain (P < 0.05) and had some effect in reducing the incidence of propofol injection pain, but the difference did not reach statistical significance. The analgesic effect of fentanyl, morphine, meperidine, and lidocaine in the peripheral veins: a comparative study. Pang WW, et al. Show-Chwan Memorial Hospital, Changhua, Taiwan. Anesth Analg 1998 Feb;86(2):382-6.

Injection Pain of Rocuronium: Lidocaine and Ondonsetron Both More Effective than Fentanyl: In a 250-patient DB PC study trying to minimize the pain of rocuronium injection, lidocaine 30 mg did better than narcotics tramadol 50 mg, and fentanyl 100 mcg with 74% vs. 60% vs. 30% experiencing no pain vs. 20% for placebo and 56% for ondansetron 4 mg. Researchers concluded that lidocaine was the most effective, and fentanyl the least. The prevention of pain from injection of rocuronium by ondansetron, lidocaine, tramadol, and fentanyl. Memis D, et al. Trakya University, Edirne, Turkey. . Anest Analg 2002 Jun;94(6):1517-20

Joints: Ketoprofen as Effective as Meperidine with Fewer Side-Effects and Longer Action: In a DB study of 59 patients undergoing painful knee arthrolysis and ligamentoplasty, carpal or foot surgery, ketoprofen was as affective as meperidine with pain relief 67% with ketoprofen vs. 63% with meperidine). Pain relief lasted 9.2 h with ketoprofen and 8 h with pethidine. Ketoprofen probably acts more through its central analgesic effect than its antiinflammatory effect. It had fewer side-effects. It does not have the risks of respiratory depression or tolerance unlike the opiate drugs. Comparative study of ketoprofen and pethidine in severe postoperative pain. Langlais F, et al. Hopital-Sud, Rennes. Ann Fr Anesth Reanim 1987;6(5):408-12.

Laparoscopic Surgery: Ketorolac Slightly Better than Hydrocodone/Acetaminophen (Vicodin): In an industry-financed DB PC study of 252 patients with moderate to severe post-op pain from arthroscopic or laparoscopic tubal ligation, patients received oral ketorolac 10 mg every 6 h for up to 3 days, or hydrocodone 7.5 mg plus acetaminophen 750 mg every 6 h for up to 3 days, or placebo capsules followed by ketorolac 10 mg every 6 h for up to 3 days. In the patients undergoing arthroscopic surgery, both ketorolac and hydromorphone-acetaminophen provided superior pain relief compared with the placebo. The summed pain intensity difference (SPID), visual analogue scale ( VAS) SPID, and total pain relief scores were higher in the ketorolac group compared with the hydrocodone-acetaminophen group, but the differences were not statistically significant. In tubal ligation surgery, the three treatment groups displayed similar responses to the study medications. However, the ketorolac group scored higher in terms of overall tolerability than the hydrocodone-acetaminophen group. Neither oral analgesic proved to be very effective after laparoscopic tubal ligation. A comparison of oral ketorolac and hydrocodone-acetaminophen for analgesia after ambulatory surgery: arthroscopy versus laparoscopic tubal ligation. White PR, Joshi GP, Carpenter RL, Fragen RJ. University of Texas Southwestern Medical Center at Dallas. Anesth Analg. 1997 Jul;85(1):37-43.

Neurosurgery: Post-Neurosurgical Pain: Pentazocine No Better Than Non-Addictive Fluproquazone: In a DB PC study of 138 adults with post-neurosurgical pain, fluproquazone 200 mg relieved pain as well as pentazocine 50 mg with both better than placebo. The importance of developing potent analgesics free of addiction potential as an alternative to the agents which act on the CNS is discussed. Comparison of the analgesic efficacy of fluproquazone, pentazocine and placebo against postoperative pain in neurosurgical patients. short communication. Hopfner R. Arzneimittelforschung 1981;31(5a):927-9.

Orthopedic Surgery: Celecoxib (Celebrex) Clearly Better than Hydrocodone/Acetaminophen: In 5-day DB PC studies of 418 patients with acute pain after orthopedic surgery, celecoxib 200 mg, was compared to hydrocodone 10 mg/acetaminophen 1000 mg, or placebo. Mean pain intensity difference (PID) favored the active treatments over placebo from 1 to 6 hours (P < or = 0.016) and favored celecoxib over the other treatments at 7 and 8 hours after dosing (P < 0.001). Over the full 5 days with each medicine given up to 3 times a day, more hydrocodone/acetaminophen patients (20%) than celecoxib patients (12%) required rescue medication (P < 0.05), and the celecoxib group had significantly lower maximum pain intensity scores (P < 0.001, days 2-5), required fewer doses of study medication (P < or = 0.01, days 3-5), and had superior scores on a modified American Pain Society Patient Outcome Questionnaire (P < or = 0.013). Celecoxib patients had many fewer adverse events (43%) compared with hydrocodone/acetaminophen (89%; P < 0.001). Efficacy and tolerability of celecoxib versus hydrocodone/acetaminophen in the treatment of pain after ambulatory orthopedic surgery in adults. Gimbel JS, Brugger A, Zhao W, Verberg KM, Geis GS. Arizona Research Center LLC, Phoenix. . Clin Ther. 2001 Feb;23(2):228-41.

Orthopedic Surgery: Morphine No Better than Ibuprofen: In a 6-hour DB study of 120 patients after orthopedic surgery for moderate to severe pain, the visual analogue scales decreased by 35 mm at 1 hour for morphine 5 mg IM, 24 mm for morphine 10 mg IM and 21 mm for ibuprofen 400 mg orally. Verbal rating scores showed a similar pattern. Comparing the groups over the whole study, the sum of pain intensity differences showed no significant differences in pain experience between the groups. Assessment of total pain relief also showed no significant differences. A comparison of ibuprofen arginine with morphine sulphate for pain relief after orthopaedic surgery. Mansfield M, Firth F, Glynn C, Kinsella J. Glasgow Royal Infirmary, UK. Eur J Anaesthesiol. 1996 Sep;13(5):492-7.

Orthopedic Surgery: Lumiracoxib Better than Oxycodone for Headaches, Orthopedic, and Dental Surgery: Lumiracoxib is a highly selective COX-2 inhibitor. In single- and multiple-dose well designed trials in patients with acute pain associated with primary dysmenorrhea, dental or orthopedic surgery or tension-type headache, lumiracoxib 100-800 mg once daily was more effective in relieving acute pain than placebo or controlled-release oxycodone 20 mg, and was at least as effective as selective COX-2 inhibitors or nonselective NSAIDs. Lumiracoxib. Lyseng-Williamson KA, et al. Adis International Limited, 

Orthopedic: Ketorolac Better than Meperidine: In a DB study of 244 patients with at least moderate pain after major orthopaedic surgery, IM Ketorolac (60 mg followed by 30 mg) did as well at 3 hours and better at 6 hours and thereafter compared to IM meperidine (100 mg or placebo) when each was given every 2 to 6 hours as needed for as many as 5 days. In both patient and observer evaluations, Ketorolac was significantly better tolerated than meperidine, and the number of patients reporting adverse events was lower with Ketorolac than with meperidine. Ketorolac was better tolerated than meperidine. Ketorolac versus meperidine for pain relief after orthopaedic surgery. DeAndrade JR, et al. Emory University. Clin Orthop Rel Res 1996 Apr;(325):301-12.

Orthopedic Surgery: IM Morphine No Better than Oral Ibuprofen 400 mg.: In a 6-hour DB study of 120 patients after orthopedic surgery for moderate to severe pain, the visual analogue scales decreased by 35 mm at 1 hour for morphine 5 mg IM, 24 mm for morphine 10 mg IM and 21 mm for ibuprofen 400 mg orally. Verbal rating scores showed a similar pattern. Comparing the groups over the whole study, the sum of pain intensity differences showed no significant differences in pain experience between the groups. Assessment of total pain relief also showed no significant differences. A comparison of ibuprofen arginine with morphine sulphate for pain relief after orthopaedic surgery. Mansfield M, Firth F, Glynn C, Kinsella J. Glasgow Royal Infirmary, UK. Eur J Anaesthesiol. 1996 Sep;13(5):492-7.

Orthopedic Post-Op Pain: Ketorolac as Good as Dextroproxyphene Combination with Fewer Side-Effects: In a DB study of 115 patients undergoing orthopedic surgery, ketorolac 10 mg did as well as dextropropoxyphene 150 mg with aspirin 350 mg and phenazone 150 mg. There were more side-effects with the dextropropoxyphene. Johansson S, et al. Gavle Hospital, Sweden. J Int Med Res 1989 Jul-Aug;17(4):324-32.

Orthopedic Surgery Post-Op Pain: Zomepirac Better than Narcotic Propoxyphene/Acetaminophen: In a DB PC study of 196 patients, zomepirac 100 mg was significantly more effective tha propoxyphene 100 mg with 650 mg acetaminophen or placebo. Patients requiring additional medication were: placebo 77%, propoxyphene/acetaminophen 48%, zomepirac 50 mg 43%, and zomepirac 100 mg 29%. Side-effects did not differ between med groups. Honig S, et al. J Clin Pharmacol 1981;21:443-8.

Post-Abortion Pain: NSAID and Acetaminophen Better than Tramadol: In a DB PC study of 217 women following surgical abortion using suppositories, indomethacin (100 mg) did best followed by acetaminophen (1000 mg), tramadol (100 mg), and control group with no suppository treatment. Pain levels were evaluated by VAS five times - 15, 30, 60, 90 and 120 min after abortion. Dipyrone (1 g po) rescue analgesia was requested by 22/55 women in the control group, 10/55 in the tramadol group, 7/54 in the paracetamol group and 5/53 in the indomethacin group (chi(2)=19.0, p<.0001). Efficacy of suppository analgesia in postabortion pain reduction. Lowenstein L, et al. Israel Institute of Technology, Haifa. Contraception 2006 Oct;74(4):345-8.

Post-Op Pain: IM Zomepirac Superior to IM Meperidine: In a DB Study of 88 patients with moderate or severe postoperative pain, IM zomepirac 100 mg. was superior to meperidine 50 mg and as effective as meperidine 100 mg. Total analgesia provided by zomepirac was greater than that with meperidine 100 mg, which was greater than that with meperidine 50 mg. Significantly fewer patients needed remedication during the observation period, and mean time to remedication was significantly longer for the zomepirac group than for either meperidine group. A double-blind study comparing single dose of intramuscularly injected zomepirac to meperidine in the treatment of postoperative pain. Baird WM, et al. Pharmacother 1986 Sep-Oct;6(5):219-27.

Post-Op Pain: Morphine Only Modestly Better than Propacetamol (IV Acetaminophen): In a DB study of 80 patients after elective surgery with expected mild to moderate post-op pain, propacetamol 30 mg/kg as a 15 min IV infusion had only a modest disadvantage in pain relief scores with 7 vs. 2 patients needing supplement pain medication (p=0.05). Nausea occurred in 4 vs. 3 but pruritis occurred in 2 vs. 7 cases. The respiratory rate was slightly slower with morphine (p=.02). No significant differences were observed in blood oxygen saturation, blood pressure, heart rate, body temperature and vigilance. Comparison of propacetamol and morphine in postoperative analgesia. Vuilleumier PA, et al. Hopital Daler, Fribourg. Schweiz Med Wochenschr. 1998 Feb 14;128(7):259-63.

Post-Op Pain: IM Ketorolac Better than IM Meperidine:In a DB study of 125 post-op patients with moderate to severe pain, ketorolac IM 30 mg or 90 mg were both superior to meperidine 50 mg IM on six of nine efficacy measures of pain over the first 6 hours. The onset of and peak analgesic effect of both doses of ketorolac and of meperidine were equivalent. Ketorolac had significantly longer duration of analgesic effect. Authors state, " The prolonged efficacy of IM ketorolac combined with the reduced risk of respiratory depression suggest an important use of this drug for the relief of postoperative pain." Efficacy and safety of single doses of intramuscular ketorolac tromethamine compared with meperidine for postoperative pain. Stanski DR, et al. Stanford University. Pharmacother 1990;10(6 ( Pt 2)):40S-44S.

Post-Op Pain: Ketorolac Better than Ibuprofen-Acetaminophen or Dextropropoxyphene-Acetaminophen: In a DB study of 160 patients with moderate to severe post-op pain, ketorolac 10 mg. resulted in greater pain relief over the six hours than ibuprofen 400 mg with acetaminophen 325 mg or propoxyphene 65 mg with acetaminophen 325. 

Post-Op Pain: Pentazocine No Better than NSAID Nefopam, But Had Many More Side-Effects: In a DB study of 50 patients undergoing surgery, nefopam did as well at relieving severe pain as pentazocine. In the nefopam group, 4/25 patients had side effects, vs. 10/25 in the pentazocine group (p< 0.05). The number of side effects was much greater in the pentazocine group (61) than the nefopam group (22) (p< 0.001). Double-blind clinical trial of nefopam in comparison with pentazocine in surgical patients. Pandit PN, et al. India. Br J Clin Pract 1989 Jun;43(6):209-14.

Post-Op Pain: NSAID Flupirtine as Good as Two Narcotics with Fewer Side-Effects: In several DB studies of post-operative pain in 586 patients, flupirtine capsules 100 mg and suppositories 150 mg were as effective and acceptable as pentazocine and dihydrocodeine for the treatment of post-operative pain, but offered advantages in terms of fewer central nervous system side effects. It was at least as effective as the non-narcotics metamizole, paracetamol and naproxen. Flupirtine in the treatment of post-operative pain. Riethmuller-Winzen H. Homburg Degussa Pharma Gruppe, Frankfurt am Main, FRG. Postgrad Med J 1987;63 Suppl 3:61-5.

Post-Op Pain: Pentazocine No Better Than NSAID Propiram: In a DB study of adults with severe postsurgical pain, 50 mg propiram did as well at relieving pain as 50 mg pentazocine or 60 mg codeine with all better than placebo. (P< 0.05). Analgesic comparison of propiram fumarate with pentazocine, codeine, and placebo in postsurgical pain. Finch JS. J Clin Pharmacol 1980 Nov-Dec;20(11-12):689-92. 

Post-Op Pain: Codeine-Acetaminophen No Better than Ibuprofen; Non-Addictive Diclofenac Better: In a DB PC study of preoperative ibuprofen 600 mg, diclofenac 100 mg, paracetamol (acetaminophen) 1g with codeine 60 mg or placebo for relief of postoperative pain in 119 patients who had operations under general anesthesia, there was no significant difference in the extent of postoperative pain among the four groups, but the placebo group had significantly shorter times before their first request for postoperative analgesics (median 17 minutes) than the diclofenac group (median 32 minutes). A double-blind randomised controlled clinical trial of the effect of preoperative ibuprofen, diclofenac, paracetamol with codeine and placebo tablets for relief of postoperative pain after removal of impacted third molars. Joshi A, Parara E, Macfarlane TV. University Dental Hospital of Manchester, UK. Br J Oral Maxillofac Surg. 2004 Aug;42(4):299-306. 

Prostate: Bupivacaine Better than Meperidine for Pain: In a DB study of 40 patients undergoing transurethral resection of prostate, 2 ml 0.5% bupivacaine intrathecally did as well at pain relief as 40 mg of meperidine intrathecally. Meperidine had significantly greater reduction in heart rate, a lower degree of motor block, shorter period before requests for postoperative analgesia but a higher incidence of sedation, nausea and vomiting. Intrathecal pethidine: an alternative anaesthetic for transurethral resection of prostate? Sia AT, et al. Toa Payoh Hospital, Singapore. Anesth Intensive Care 1997 Dec;25(6):650-4.

Pulmonary: IM Ketamine as Good as IM Meperidine: In a DB study of 30 pulmonary surgery patients, IM ketamine (1 mg/kg) did as well as relieving pain as meperidine (1 mg/kg); however, the duration of action of ketamine appeared to be slightly longer. Throughout the study PaCO2 was significantly lower in the ketamine group. Heart rates increased significantly only with meperidine. Intramuscular low-dose ketamine versus pethidine for postoperative pain treatment after thoracic surgery. Dich-Nielsen JO, et al. University of Copenhagen, Denmark. Acta Anesth Scand 1992 Aug;36(6):583-7. 

Shoulder Surgery: Bupivacaine Better than Oxycodone for Pain: In a DB study of 42 patients after shoulder surgery with general anesthesia, those receiving 10 ml of 0.5% bupivacaine in the subacromial bursa did just as well for pain reduction as those given 5 mg of oxycodone in 10 ml of saline over the first 24 hours. Those receiving 5 mg of oxycodone intramuscularly did do as well, consuming more total perioperative fentanyl for complaints of pain (1.61 mg vs. 0.97 for bupivacaine and 1.23 for intrabursal oxycodone). Comparison of the analgesic effects of intrabursal oxycodone and bupivacaine after acromioplasty. Muittari PA, et al. Turku University Hospital, Finland. J Clin Anesth. 1999 Feb;11(1):11-6. Ed: Please note that there was absolutely no evidence that the narcotic fentanyl was needed.  It is virtually certain that a non-narcotic pain reliever such as ketorolac or diclofenac would have worked better as a far lower cost and no danger of increasing the future risk of addiction.

Spinal Anesthesia Study: Levobupivacaine Alone Did Just as Well; Fentanyl Added No Benefit: Fentanyl has been used as an adjunct to racemic bupivacaine in spinal anaesthesia. In a DB study of 50 patients undergoing urological surgery with spinal anesthesia, 2.6 mL of 0.5% levobupivacaine alone did just as well as 2.3 mL of 0.5% levobupivacaine with fentanyl 15 microg in 0.3 mL. The study solution was injected into the subarachnoid space at the L3-L4 interspace. There were no significant differences between the two groups in the haemodynamic changes, and quality of sensory and motor block. Levobupivacaine and fentanyl for spinal anaesthesia: a randomized trial. Lee YY, et al. Kwong Wah Hospital, Hong Kong SAR. . Eur J Anesthiol 2005 Dec;22(12):899-903.

Tonsillectomies: Acetaminophen as Good as Acetaminophen with Codeine for Tonsillectomies; Fewer Side-effects: In a DB study of 51 children ages 3 to 12 with outpatient tonsillectomy, there was no difference in the level of postoperative pain reported by the parents and children between plain acetaminophen and acetaminophen with codeine. The acetaminophen with codeine group tended to have increased problems with nausea, emesis, and constipation. Children in the acetaminophen group consumed a significantly higher percentage of a normal diet on the first 6 postoperative days (P < .05, all time points). Acetaminophen versus acetaminophen with codeine after pediatric tonsillectomy. Moir MS, et al. Stanford University. Laryngoscope. 2000 Nov;110(11):1824-7.

Tonsillectomy: Ketorolac Caused Much Less Vomiting but Somewhat More Bleeding than Morphine: In a DB study of 96 children after tonsillectomy, received morphine 0.1 mg/kg (n = 47) or ketorolac 1 mg/kg (n = 49) intravenously (IV) in a prospective, randomized, double-blind fashion, after tonsillectomy. Ketorolac subjects had fewer emetic episodes than morphine subjects (median 1 vs 3; P = 0.006) and were less likely to have more than two episodes of emesis after PACU discharge (9/49 vs 22/47; P = 0.007). Ketorolac subjects had more bleeding requiring intervention; 5/49 vs 0/47, one-tailed P = 0.03) and more bleeding episodes (0.22 episodes/subject vs 0.04 episodes/subject, P < 0.05) in the first 24 h after surgery, but no greater overall incidence of bleeding than the morphine subjects. In children having tonsillectomy, ketorolac, compared to morphine, reduced the number of emetic episodes after PACU discharge, but did not hasten awakening, readiness for PACU discharge or discharge home. Recovery and complications after tonsillectomy in children: a comparison of ketorolac and morphine. Gunter JB, Varughese AM, Harrington JF, Wittkugel EP, Patandar SS, Matar MM, Lowe EE, Myer CM 3rd, Willging JP.  University of Cincinnati. Anesth Analg. 1995 Dec;81(6):1136-41. Ed: This study is strange in that it didn't study pain, which is the primary reason these medicines were given. If Ketorolac was better for pain (very likely), that would be an important benefit to consider, in addition to its lack of priming for future addiction, in making a decision on which to use. According to the above, for every extra bleeding requiring intervention caused by ketorolac, morphine causes 20 episodes of vomiting.

Total Gastrectomy: Fentanyl No Better Pain Relief than Ketamine, But More Low Blood Pressure: In a DB study of 40 patients undergoing total gastrectomy, the effects of intraoperative epidural administration of ketamine added to bupivacaine were compared with fentanyl added to bupivacaine. Those receiving 50 ug of fentanyl did no better for pain relief or time to extubation than those on 50 mg of ketamine. Statistically significant more ephedrine was needed with the fentanyl for low blood pressure (F vs.K = 0.88(1.76)ml vs.0.05(0.23)ml) (p > 0.05). Epidural analgesia in total gastrectomy--combination of bupivacaine with ketamine or fentanyl. Jankovic Z, et al. Beograd . Acto Chir Iugosl 1999;46(1-2):47-52

Vaginoplasty: Intrathecal Neostigmine as Good as Morphine: In a DB study of 48 women undergoing anterior and posterior vaginoplasty, intrathecal neostigmine did as well as morphine for pain relief. Combining both at lower doses also did as well. Increasing doses of intrathecal morphine (50 micrograms, 100 micrograms, and 200 micrograms) and intrathecal neostigmine (50 micrograms, 100 micrograms, and 200 micrograms) showed a dose-dependent pattern of analgesia (P < 0.001). The M50 + N50 combination resulted in a better analgesic effect with fewer side effects than M50, N50, and control groups. Dose-response study of intrathecal morphine versus intrathecal neostigmine, their combination, or placebo for postoperative analgesia in patients undergoing anterior and posterior vaginoplasty. Lauretti GR, Reis MP, Prado WA, Klamt JG. Faculdade de Medicina de Ribeirao Preto-USP, Sao Paulo, Brazil. Anesth Analg. 1996 Jun;82(6):1182-7.

Varicose Vein Surgery: Oxycodone No Better than Lysine Acetylsalicylate: Lysine acetylsalicylate (LAS) is a soluble salt of acetylsalicylic acid and can be given parenterally. LAS 12.5 mg/kg and 25 mg/kg were compared with oxycodone 0.15 mg/kg in the treatment of pain after operation in 60 patients undergoing varicose vein surgery. Both treatments almost completely relieved moderate to severe pain for the 3-h observation period. The time until the peak of action was longer after LAS (60-90 min) than after oxycodone (30-60 min). No significant differences were found between the smaller and larger doses of LAS. Comparison of i.m. lysine acetylsalicylate and oxycodone in the treatment of pain after operation. Korttila K, et al. Br J Anaesth. 1980 Jun;52(6):613-7.

Animal Surgery

NSAID Ketoprofen (Orudis) Did Better than Oxymorphone for Post-Surgical Hind Limb Pain in Dogs: In a random-assignment study of 70 dogs undergoing orthopedic surgery on a hind limb, ketoprofen, oxymorphone hydrochloride, and butorphanol were compared for the control of postoperative pain. If the pain score was > or = 9, supplemental oxymorphone was administered IM. The ketoprofen alone and ketoprofen-oxymorphone groups did significantly better than the oxymorphone alone group. During the first hour after surgery, pain score was lower for oxymorphone alone and ketoprofen-oxymorphone groups than for ketoprofen or butorphanol alone groups. Significant differences were not detected among groups in regard to pain score 2 and 3 hours after surgery or in regard to arterial blood pressures at any time. From 4 to 12 hours after surgery, pain score was significantly lower for the ketoprofen alone group than for other groups. Except during the first hour after surgery, dogs given ketoprofen alone after elective orthopedic surgery had a greater level of, and longer-lasting, analgesia than did dogs given oxymorphone or butorphanol alone. Comparison of ketoprofen, oxymorphone hydrochloride, and butorphanol in the treatment of postoperative pain in dogs. Pibarot P, et al. University of Montreal, Canada. J Am Vet Med Assoc 1997 Aug 15;211(4):438-44. Ed: Ketoprofen (Orudis) is readily available in the U.S. for humans with a prescription for just $32 for 60 pills of 75 mg each, taken one three times a day. A long-acting form is available as Oruvail 200 mg once a day. The IM form is available as well. Believe it or not. This study and the one below are apparently the only two studies ever done anywhere in the world comparing oxymorphone to a non-narcotic. Otherwise, I have not included animal studies on the narcotic vs. non-narcotic issue.

Ketorolac (Systemic) Much Better than Oxymorphone for Post-Surgical Laparotomy and Shoulder Arthrotomy Pain in Dogs: In a DB random-assignment study, ketorolac was compared with flunixin and butorphanol after laparotomy or shoulder arthrotomy in 64 dogs (butorphanol 0.4 mg/kg body weight (BW), flunixin 1.0 mg/kg BW, or ketorolac 0.5 mg/kg BW. The analgesic efficacy was (1 = inadequate, 4 = excellent) after laparotomy: ketorolac, 3.4; flunixin, 2.7; and butorphanol, 1.6. After shoulder arthrotomy, the average scores were ketorolac, 3.5; flunixin, 3.0; and butorphanol, 1.4 (5/11 dogs). As butorphanol was unable to control pain after shoulder arthrotomy, oxymorphone, 0.05 mg/kg BW, replaced butorphanol in a subsequent group of dogs and had a score of 2.0 (6/11 dogs). We concluded that ketorolac is a good analgesic for postoperative pain in dogs. A comparison of ketorolac with flunixin, butorphanol, and oxymorphone in controlling postoperative pain in dogs. Mathews KA, et al. Ontario Veterinary College, University of Guelph. Can Vet J 1996 Sep;37(9):557-67.

Thomas E. Radecki, M.D., J.D.

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