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Ibuprofen + acetaminophen equals opioid + acetaminophen for acute severe extremity pain
Clinical Question
What oral analgesic combinations are effective for reducing the pain of an acute extremity injury in adults in the emergency department?
Bottom line
In adults presenting to the emergency department with acute extremity pain severe enough to warrant radiologic investigation, ibuprofen plus acetaminophen was equally effective in reducing pain intensity at 2 hours compared with 3 different opioid and acetaminophen combination analgesics. In a similar study (Friedman BW, et al. JAMA 2015;314(15):1572-80), naproxen alone was as effective as naproxen plus oxycodone/acetaminophen or naproxen plus cyclobenzaprine for reducing pain from acute musculoskeletal low back pain. It's time we stopped believing that opioids are superior to nonsteroidal anti-inflammatory drugs for acute pain control. We'd save a lot of lives. 1b
Reference
Study design: Randomized controlled trial (double-blinded)
Funding: Government
Setting: Emergency department
Synopsis
Opioid use for just 3 days can significantly increase the risk of opioid dependence. These investigators identified adults, aged 21 to 64 years, presenting to the emergency department for acute extremity pain, defined as pain originating distal to and including the shoulder joint in the upper extremities and distal to and including the hip joint in the lower extremities. Eligible patients (N = 411) included those with an injury severe enough to require radiologic imaging according to the judgment of the attending physician. After baseline pain measurement, patients randomly received (concealed allocation assignment) identical capsules containing either ibuprofen 400 mg plus acetaminophen 1000 mg; oxycodone 5 mg plus acetaminophen 325 mg; hydrocodone 5 mg plus acetaminophen 300 mg; or codeine 30 mg plus acetaminophen 300 mg. Patients masked to their treatment group assignment self-assessed pain intensity using a verbal numerical rating scale from 0 (no pain) to 10 (worse pain imaginable). The minimum clinically important difference was predefined as a mean pain scale score of 1.3. Complete follow-up occurred for 100% of patients at 2 hours. Using intention-to-treat analysis, pain intensity significantly declined by 3.5 to 4.4 points at 2 hours compared with baseline in all treatment groups, but was not significantly different among the 4 groups. Pain intensity was also similarly reduced in all treatment groups at 1 hour and there were no group differences in the use of rescue analgesia. Even with post hoc analysis, no statistical difference was present for those with 10/10 pain (severe) and those with acute fractures.
Reviewer
David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Atrium Health
Professor of Family Medicine, UNC Chapel Hill
Charlotte, NC
Comments
Good poem
what evidence is there that 3 days of opioid use increases opioid dependence? what numbers are we talking about?
Extremely relevant study to many primary care practitioners.
Study design makes it easy to comprehend and therefore easier to relate when informing patients and guiding care
dose?
It's a shame the researchers used inappropriate doses of the opioids. This study just shows that 1000mg of Acetomenophen works better than 300mg.
Useless study
Needs to be repeated using 1000mg of acetaminophen. This seems designed solely to discredit opioid use and unfortunately adds little if anything to my ED practice
if the goal with this study is opioid use reduction, then the acetaminophen doseage for all arms should have been 1000 mg!
I have used or seen patient how has used this combination a lot although most of patient initially used then add then to ER with sever acute radicular pain most of meds did not worked morphine was effective
post op pt treated with tylenol and codeine for average of 10 days then used over counter medication. in acute cases pain medication should work immediately 3-4 hour to pain relief is not acceptable , addiction and dependence is rare most of addict has got their meds from street. long term term opioid treatment may result in addiction , but it is very seldom required except in painful cancer cases which normally treated by oncololgy , Also I have one should consider liver and kidney side effect
Inappropriate moralizing about use of ibuprofen/nsaids in acute pain management. Hazards only recently unearthed in pediatric and adult populations. Threatening so called addiction risk academically unethical.
I am encouraged by the possibilities this POEM present. I am distressed by the reviewer's inability to point out that 1000 acetaminophen in one arm is NOT COMPARABLE to 325 mg acetaminophen used in the other options. Is this paper actually evidence that 1000 mg acetamin is a highly superior dosage?
Finally two papers that say - give NSAID with or without acetaminophen and you can forget the narcotics. I hope I never write a prescription for Percocet or T3's again! Now if I can only convince my colleagues that IM/IV ketorolac is no better than PO NSAIDS (or if you must 10 mg of IM/IV ketorolac is all you need) then I can rest happy. (OK except for renal colic where patients vomit a lot).
I hardly ever use opioids . It is good to know that the combination of Tylenol and NSAID has similar effect on pain relief . The one thing that needs further study is how long does the relief last and does the same effect hold with prolonged use-like one to two weeks?
It would be nice to know what other types of pain this type of result extends to that would be more relevant to my practice
bad poem
Another nail in the coffin of narcotics. There is, however, a better way to treat acute, severe low back pain which takes two minutes and provides complete pain relief in 50% of those treated. https://www.youtube.com/watch?v=NXNS6PNKRPo
This is not well designed. The dose of opioids is very small. The mean pain score on arrival is high at 8.7. Larger initial doses of analgesic is required to knock that down to a point where smaller doses are effective ("pain is easier to prevent than it is to cure"). This is another opinion demonizing the appropriate use of opioids. The problem is not the initial treatment of acute pain but the ongoing inappropriate use of opioids without step down and introduction of adjunctive therapies where required.
Excellent!
Extremity Pain control
Glib and unprofessional POEM. Cruel physicians misunderstand or misuse statistics if they think the entire group responds the same way to a given treatment. Overwhelming evidence that different people absorb, metabolize and respond to medications differently. Are we losing sight of the need to help our patients, even if we have to work a little to understand why?