BACKGROUND AND PURPOSE:

• Almost 500,000 people have died since 2000 from drug overdoses
• Opioid analgesics still remain a first line choice for moderate to severe acute pain in emergency departments
• The choice of analgesic to treat acute extremity pain lacks a clear evidence base
• Chang et al. (JAMA, 2017) compared the efficacy of 4 opioid and non-opioid oral analgesics

METHODS:

• Randomized blinded clinical trial (RCT)
• Inclusion
  • Adults 21 – 64 years
  • Acute extremity pain, sufficient to require radiological imaging
• Participants were randomized into the following groups
  • 400 mg ibuprofen and 1000 mg acetaminophen
  • 5 mg oxycodone and 325 mg acetaminophen
  • 5 mg hydrocodone and 300 mg acetaminophen
  • 30 mg codeine and 300 mg acetaminophen
• After randomization, patients rated their pain before and after taking the study medication at 1 and 2 hours
• Pain intensity was measured using an 11-point numerical rating scale (NRS), with 0 indicating no pain and 10 worst possible pain
  • Minimum clinically important difference – 1.3
• Primary outcome: Between-group difference in decline in mean NRS score at 2 hours after ingestion
• Secondary outcomes: Between-group differences in mean NRS scores at 1 hour and responses to a 4-point Likert scale rating pain as none, mild, moderate, or severe

RESULTS:

• Data from 411 patients were analyzed
  • Mean age 37 years; 199 (48%) women; 247 (60%) Latino
• The baseline mean NRS pain score was 8.7 (SD, 1.3)
• After 2 hours the NRS score decreased by
  • 4.3 (95% CI, 3.6 to 4.9) in the ibuprofen and acetaminophen group
  • 4.4 (95% CI, 3.7 to 5.0) in the oxycodone and acetaminophen group
  • 3.5 (95% CI, 2.9 to 4.2) in the hydrocodone and acetaminophen group
  • 3.9 (95% CI, 3.2 to 4.5) in the codeine and acetaminophen group
• Primary Outcome: There was no statistical difference in change in pain by treatment group from baseline to 2 hours (P=0.53)
  • Nor was there difference at 1 hour (P=0.13)
• The largest difference in decline (between the oxycodone and acetaminophen group and the hydrocodone and acetaminophen group) was still less than the minimum clinically relevant difference of 1.3

CONCLUSION:

• There was no measured difference in efficiency of analgesic treatment between combination opioid/acetaminophen and ibuprofen/acetaminophen
• Previous studies were undertaken in the post-op or dental setting and likewise did not find opioid/acetaminophen to be superior to ibuprofen/acetaminophen
  • Authors therefore suggest that this study may be generalizable beyond acute extremality pain
• Future research is needed to assess adverse events and alternative dosing

Learn More – Primary Sources:

Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department A Randomized Clinical Trial

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