Should Emergency Rooms Cut Back on Opioid Use?

As the U.S. struggles with an opioid epidemic, with almost 500,000 individuals dying from opioid overdoses since 2000, one study may shed light on how “overprescribed” such medications might be. Despite the fact that opioid analgesics remain a first-line treatment for moderate to severe acute pain in the emergency department, the research found that patients coming into an emergency room with acute arm or leg pain had no significant difference in pain relief from opioids versus over-the-counter pain relief. In fact, researchers found that in many cases, the combination of ibuprofen and acetaminophen may represent an effective non-opioid alternative.

This study included 416 patients (ages 21 to 64 years) with moderate to severe acute extremity pain in two urban emergency departments were randomly assigned to receive:

  • 400 mg ibuprofen and 1,000 mg acetaminophen
  • 5 mg oxycodone and 325 mg acetaminophen
  • 5 mg hydrocodone and 300 mg acetaminophen; or
  • 30 mg codeine and 300 mg acetaminophen

For adults coming to the emergency department for arm or leg pain due to sprain, strain, or fracture, there was no difference in pain reduction after 2 hours with ibuprofen-acetaminophen vs three comparison opioid-acetaminophen (paracetamol) combinations, report Andrew K. Chang, M.D., M.S., of Albany Medical College, Albany, New York, and coauthors.

The study measured the between-group difference in decline in pain two hours after taking the study drugs.

This was a randomized clinical trial (RCT). Randomized trials allow for the strongest inferences to be made about the true effect of an intervention such as a medication or a procedure. However, not all RCT results can be replicated because patient characteristics or other variables in real-world settings may differ from those that were studied in the RCT.

After 2 hours pain was less in all participants, without any important difference in effect between the four groups.

Stating the study’s limitations, the researchers report that results apply only to pain after two hours. About 1 in 5 patients required additional medication to control their pain.

In conclusion, there were no important differences in pain reduction after 2 hours with ibuprofen-acetaminophen or opioid-acetaminophen combination pills in emergency department patients with acute extremity pain. The findings suggest that ibuprofen-acetaminophen is a reasonable alternative to opioid management of acute extremity pain due to sprain, strain, or fracture, but further research to assess longer-term effect, adverse events and dosing is warranted.

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