Adults of any age who are at increased risk, including smok- ers and those with asthma, should also be given the vaccine. Immunocompromised adults should receive the 13-valent conjugate vaccine in addition to the 23-valent vaccine.464 466 The influenza vaccine is discussed in Section 6.4. 6.3.4. NSAIDs: Recommendations Class I 1. Before hospital discharge, the patient s need for treat- ment of chronic musculoskeletal discomfort should be assessed, and a stepped-care approach should be used for selection of treatments. Pain treatment be- fore consideration of NSAIDs should begin with ac- etaminophen, nonacetylated salicylates, tramadol, or small doses of narcotics if these medications are not (Level of Evidence: C) Class IIa 1. It is reasonable to use nonselective NSAIDs, such as naproxen, if initial therapy with acetaminophen, nonacetylated salicylates, tramadol, or small doses of narcotics is insufficient.237 (Level of Evidence: C) Class IIb 1. NSAIDs with increasing degrees of relative COX- 2 selectivity may be considered for pain relief only for situations in which intolerable discomfort per- sists despite attempts at stepped-care therapy with acetaminophen, nonacetylated salicylates, tramadol, small doses of narcotics, or nonselective NSAIDs. In all cases, use of the lowest effective doses for the shortest possible time is encouraged.234,235,237,467 (Level of Evidence: C) Class III: Harm 1. NSAIDs with increasing degrees of relative COX- 2 selectivity should not be administered to patients with NSTE-ACS and chronic musculoskeletal dis- comfort when therapy with acetaminophen, nonac- etylated salicylates, tramadol, small doses of narcot- ics, or nonselective NSAIDs provide acceptable pain (Level of Evidence: B) Selective COX-2 inhibitors and other nonselective NSAIDs have been associated with increased cardiovascular risk, and the risk appears to be amplified in patients with established. 