Codeine-acetaminophen versus nonsteroidal anti-inflammatory drugs in the treatment of post-abdominal surgery pain: a systematic review of randomized trials.

Cesarean section, episiotomy, and third and perineal tears are associated with significant tissue damage, causing pain in the immediate postpartum period. The current standard in North America is to prescribe oral acetaminophen/codeine (A + C) for postpartum pain. Codeine has opioid-related adverse effects and may not be safe during breastfeeding in the postpartum period for all neonates. Nonsteroidal anti-inflammatory drugs (NSAIDs) are devoid of opioid-related adverse effects and could be a possible alternative for analgesia in postpartum pain. The objective of this systematic review was to compare the analgesic effect and safety profile of acetaminophen/codeine (A + C) with NSAIDs in the management of pain after laparotomy. A systematic search was performed by using MEDLINE, EMBASE, CINAHL, and Cochrane Library databases to identify randomized controlled trials comparing A + C to NSAIDs for postlaparotomy pain. Selected articles were critically appraised by using the CONSORT method and Jadad score. Nine relevant articles were identified. All 9 studies used a visual analog scale for pain intensity and reported the incidence of adverse effects as an outcome. None of the studies showed lower pain intensity scores after treatment with A + C compared with different NSAIDs. In 3 studies, the number of patients with adverse effects was significantly lower in the NSAID group compared with the A + C-group. In 1 other study, the rate of constipation was significantly lower in the NSAID group when compared with the A + C-group. The other 5 studies did not report any significant differences in the rates of adverse effects between the 2 groups. None of the studies found A + C to be superior to NSAIDs in controlling postlaparotomy pain. NSAIDs appear to be an equipotent alternative in the treatment of postlaparotomy pain. Four of the 9 studies reported less adverse effects in the NSAID group. There appears to be an overall better risk/benefit ratio for the use of NSAIDs for postpartum pain.