Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions
Opioid vs Nonopioid Pain Reduction in the ED
JAMA; 2017 Nov 7; Chang, Bijur, et al
For adult patients presenting to the emergency department (ED) with acute extremity pain, there were no clinically important differences in pain reduction at 2 hours with ibuprofen and acetaminophen or 3 different opioid and acetaminophen combination analgesics. This according to a randomized clinical trial that included 411 patients aged 21 to 64 years with moderate to severe acute extremity pain enrolled from July 2015 to August 2016. Participants (400 in each combination analgesic group) received 400 mg of ibuprofen and 1000 mg of acetaminophen; 5 mg of oxycodone and 325 mg of acetaminophen; 5 mg of hydrocodone and 300 mg of acetaminophen; or 30 mg of codeine and 3000 mg of acetaminophen. The primary outcome was the between-group difference in decline in pain 2 hours after ingestion. Researchers found:
- The baseline mean numerical rating scale (NRS) score was 8.7.
- There was no significant difference in pain reduction at 2 hours.
- Mean pain scores decreased by 4.3 with ibuprofen and acetaminophen; 4.4 with oxycodone and acetaminophen; 3.5 with hydrocodone and acetaminophen; and 3.9 with codeine and acetaminophen.
- Adverse events were not assessed.
Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department. A randomized clinical trial. JAMA. 2017;318(17):1661–1667. doi:10.1001/jama.2017.16190.
This Week's Must Reads
Must Reads in Pain
Sleep Disturbance and Chronic Pain Intensity, Clin J Pain; ePub 2019 Mar 25; Burgess, et al
Almost 20% of patients discharged from emergency rooms receive opioids upon discharge. This study looked at the effectiveness of a simple combination of ibuprofen 400 mg and acetaminophen 1000 mg compared to various opioids in combination with acetaminophen, and showed no difference in reduction in pain between the opioid regimens and the simple ibuprofen/acetaminophen regimen. This study, conducted in a large number of patients with a great deal of validity, makes us examine our assumptions about the effectiveness of opioids above that of ibuprofen/acetaminophen, and can be integrated into practice tomorrow. Very simply, first-line treatment for control of acute pain should be an NSAID and acetaminophen, with opioids being reserved for cautious use in individuals who do not have sufficient pain control after first line treatment. —Neil Skolnik, MD