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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-
Reference
Study design: Randomized controlled trial (double-blinded)
Funding: Self-funded or unfunded
Setting: Emergency department
Synopsis
These researchers enrolled 162 patients, 65 years and older, who presented to 1 of 2 emergency departments with acute pain (average score 9 out of 10 on a verbal pain scale) deemed to require intravenous opioid treatment. More than half the patients eligible for the study declined to participate. The patients, using concealed allocation, were randomized to receive intravenous acetaminophen 1000 mg over 10 minutes or hydromorphone (Dilaudid) 0.5 mg via slow intravenous push. Each treatment was paired with a placebo to mask treatment assignment. The main study outcome, pain scores at 1 hour, were decreased in both groups — an average decrease of 3.6 points with acetaminophen and 4.6 points with hydromorphone (difference 1.0; 95% CI 0.1 - 2.0). In other words, patients in both groups reported an average pain level between 4 and 6 after 1 hour. One-quarter of the participants did not experience clinically noticeable improvement in pain; that is, a decrease in pain of at least 1.3 points. The percentage of patients who received additional analgesic while in the emergency department was similar between the 2 groups: 46% and 38%)
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Comments
Impact assessment
Very good
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?
IV Hydromorphone
0.5mgm is almost a homoeopathic dose. I am not surprised that it didn't work
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.
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
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.
iv hydromorphone vs iv acetaminophen for acute severe pain i
hydromorphone under dosed.
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?
IV acetaminophen vs. IV hydromorphine
Hard to believe they have equivalent efficacy!
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.
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.
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.