Emergency Pain Treated Equally By Opioids, Non-Opioids

credit/docs title

Andrew Chang, MD, MS

Tylenol and Motrin may get same the job done as opioids in emergency department (ED) pain reduction, according to a new study.

In a comparison of 4 oral combination analgesics, researchers were unable to find a statistically significant or clinically important difference in acute extremity pain reduction in ED patients taking either single-dose ibuprofen and acetaminophen regimen or 1 of 3 different opioid and acetaminophen combinations.

The researchers — led by Andrew Chang, MD, MS, Vice Chair of Research and Academic Affairs, and Professor of Emergency Medicine at Albany Medical Center — studied patients with moderate-to-severe acute extremity pain from 2 urban EDs in the Bronx, NY, between July 2015 and August 2016.

The 416 patients were randomized evenly into 4 therapy groups: 400mg ibuprofen and 1,000mg acetaminophen; 5mg oxycodone and 325mg acetaminophen; 5mg hydrocodone and 300mg acetaminophen; 30mg codeine and 300mg acetaminophen.

Gauging pain intensity on an 11-point numerical rating scale (NRS) 2 hours following administration, Chang and company found little differences among treatment groups.

The ibuprofen and acetaminophen groups’ NRS pain score reduced by 4.3; the oxycodone group reduced by 4.4; the hydrocodone group reduced by 3.5; and the codeine group reduced by 3.9. None of the groups’ differences in mean NRS reached the clinically-important scale of 1.3.

Chang told MD Magazine that, though it wasn’t the basis of the study, it doesn’t take “a huge leap of faith” to conclude that non-opioid combination therapy would provide similar extremity pain relief as an opioid counterpart in an outpatient setting, as well.

“This dose in the ED almost serves like a trial dose,” Chang said. “By preventing exposure to opioids in the first place, it should help in the overall opioid epidemic.”

Chang acknowledged that “fairly high doses” for non-opioid therapies were given to patients. He referenced the TYLENOL (acetaminophen) daily maximum dose guideline being set at 3,000mg. The research team set the dosing at 1,000mg with consideration to 3-times-per-day regimens.

Prior to the study, Chang’s personal perspective of administering acetaminophen and ibuprofen was limited to alternating the generic therapies in treating children’s fevers. The researchers did not believe either therapy alone could serve the same pain relief as an opioid.

The only country to manufacture and sell an ibuprofen/acetaminophen combination pill is New Zealand, Chang said. His hope was this and follow-up studies would give weight to the idea for US agencies.

Chang also hoped further studies could convince patients and prescribing physicians alike that an alternate to opioids is just as effective in extremity acute pain relief.

“We know that a certain percentage of patients who are prescribed on opioid will subsequently become addicted to an opioid,” Chang said. “But if we can administer a combination of non-opioids to patients while they are in the ED and show them (as well as the treating physician) that it provides comparable pain relief to opioids, then the patient will likely be more accepting of a non-opioid upon discharge, and the physician may feel less pressure to prescribe an opioid.”

Chang is now pursuing grant funding for a follow-up study observing the combination drug regimens’ effects treating pain in at-home scenarios. Though it could cement reason for physicians to refrain from opioid prescription when they don’t have to, the initial study has already made that argument.

“The reason you do the study is because you don’t know the answer,” Chang said. “You can’t just tell physicians to suddenly stop prescribing opioids without providing evidence that non-opioid options exist.”

The study, "Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department," was published online in JAMA on Tuesday.

Related Coverage

FDA Approves sNDA for Abuse Deterrent, Extended-Release Oxycodone

FDA Panel Recommends CAM2038 in Opioid Use Disorder

RedHill Biopharma Submits NDA for New Rizatriptan Formula