NSAIDs, either traditional nonselective or COX-2–selective agents, are generally more efficacious than analgesics alone. Although all NSAIDs, selective or nonselective, have the potential for gastrointestinal complications such as peptic ulceration, perforation or obstruction, the COX-2–selective agents appear to be less of a risk in this regard. If nonselective NSAIDS are used, either a proton pump inhibitor or a prostaglandin analog such as misoprostol can be added to protect the gastrointestinal tract.

Of concern was the observation that COX-2–selective NSAIDs were associated with significant cardiovascular side effects, including myocardial infarction. Unfortunately, cardiovascular side effects may be observed with traditional COX-1/COX-2–inhibiting NSAIDs as well. COX-2–selective NSAIDs are specifically contraindicated in the treatment of peripheral pain in the setting of coronary artery bypass surgery. The risk-benefit ratio of any therapeutic agent is key in regard to indications for its use, and a considered balancing of the benefits of diminished pain with improved quality of life versus therapeutic risk is an important consideration in any treatment paradigm.

Weak opioid therapy, carefully considered, is an important therapeutic option in patients with chronic pain related to peripheral joint or spine osteoarthritis not responding to other analgesics. As in all use of such agents, careful assessment for potential abuse is important. Adverse events such as constipation, nausea, and appetite loss, particularly in older individuals in whom osteoarthritis is more likely to be present, may limit their use.