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#Grand Rounds

Do Non-Opioids Work as Well as Opioids for Acute Extremity Pain? 

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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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