IV hydromorphone slightly better than IV acetaminophen for severe pain, but neither is very effective

Clinical Question

In older adults who present to the emergency department with severe pain, is a single dose of intravenous acetaminophen as effective as a single dose of hydromorphone to relieve pain?

Bottom line

For older adults who present to an emergency department with acute pain, both intravenous acetaminophen and intravenous hydromorphone produced similar pain reduction, on average. However, neither, on average, produced dramatic relief from pain, and 1 in 4 patients did not notice any pain relief 1 hour after treatment. Hydromorphone produced slightly lower average pain scores, but a substantial percentage of patients treated with either analgesic will need additional pain treatment. 1b-

Study design: Randomized controlled trial (double-blinded)

Funding: Self-funded or unfunded

Setting: Emergency department

Reviewer

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA


Discuss this POEM


Comments

ARUP KUMAR DHARA

Impact assessment

Very good

Anonymous

IV acetaminophen

Sounds not unreasonable to give a trial of IV acetaminophen and thereby avoid unnecessary opioids or even reduce opioid needs. The bigger question: Is IV acetaminophen available?

Lindsay Pritchett

IV Hydromorphone

0.5mgm is almost a homoeopathic dose. I am not surprised that it didn't work

Pieter Richard Verbeek

Acet vs Hydromoph for acute pain in ED

Not surprised but disappointed since once again we learning how difficult it is to manage acute pain in the ED including how limited opioids can be compared to other pharmacologic options. Once could argue that the study is quite small, lots of potential subjects declined and there is no description of the causes of ;pain. Would have been great to know what kinds of rescue medications were used and what the "final" pain score was. Bottom line for me is that this study is yet another example that justifies an intensive, large-scale multicentre effort to do large studies of analgesia in the ED that will allow for pre-specified subgroup analyses of various clinical groups. Wouldn't it be great if we could largely eliminate use of opioids based on solid evidence. Unfortunately small scale studies such as this one almost never lead to a change in practice but they should inspire us to get really serious about taking this on as noted above.

Anonymous

problem with syudy design

I am not sure what this proves . perhaps this study group was simply underdoses with the hydromorphone at 0.5 mg

Debbie Phillips

acetaminophen vs hydromorphone for acute pain.

It's encouraging that acetaminophen almost matches hydromorphone in this initial dose but given the still high levels at one hour, patients were clearly underdosed. I usually give hydromorphone at 1-2 mg iv for severe pain. I agree that we need larger and more detailed subgroup analysis before we can change practice on this important issue.

Anonymous

iv hydromorphone vs iv acetaminophen for acute severe pain i

hydromorphone under dosed.

Anonymous

iv acetaminophen vs hydromorph

Did the authors really expect the equivalent of 5 mg oral morphine (or 1 Tylenol #3) to have significant benefit in patients with severe, acute pain?

Anonymous

IV acetaminophen vs. IV hydromorphine

Hard to believe they have equivalent efficacy!

Anonymous

The dose of 0.5 mg Hyrdomorphone iv may be a poor choice in

I am surprised such a small dose of Hydromorphone (0.5 mg iv) helped any patient with a pain score of 9-10. One can start with Hydromorph 0.5 mg (equivalent to Morphine 2mg iv) to monitor response in the elderly, but should then expect to titrate the dose up in the ER, rather than leaving people to suffer for an hour. This explains the large number of study patients (25%) not experiencing pain relief at an hour. This review does not demonstrate that acetaminophen replaces an opioid for severe abdominal pain. One must use a dose appropriate to circumstances (ie. titration). Acetaminophen may act as an adjunct and may allow a lower total dose of opioid, as has been demonstrated in other studies, but does not replace opioids in this circumstance nor can be thought of as "nearly equivalent" to hydromorphone.

Anonymous

Analgesia for severe pain

I hope this study does not lead clinicians to believe that hydromorphine and acetaminophen are interchangeable when treating severe pain. I've had both an ACL tear and a lumbar disc herniation and would not dream of using acetaminophen as a sole agent for analgesia for patients with similar injuries. As a co-analgesic, yes. Like it or not, sometimes opioids are a necessity, but need to be titrated carefully and monitored for both efficacy and harmful side effects.

Eric Nicholas Kaziuka

IV hydromorphone vs. IV acetaminophen for acute pain

After practicing for 40 years, it seemed that I always knew that any analgesic will only reduce your pain by 3 points! That's where people run into issues, they expect to have no pain.