Published by Robert Broida on Nov-09-17

New Study Shows Adequate Acute Pain Control Achieved in the ED Without Use of Opioid Medications

While an ED opioid prescription is not typically the initial source for most people who become addicted, the fact remains that we see a lot of patients with acute painful conditions and prescribe a lot of opioids. Because of this, we need to be mindful of our prescribing practices and evaluate reasonable alternatives to these highly addictive medications.

There was a recent study published in JAMA, which compared 4 types of oral analgesics for acute pain in the emergency department. It is important because it was a head-to-head comparison of non-opioid vs. opioid pain relievers.

There were approximately 100 patients in each group, and all patients had “severe acute extremity pain.” The 4 groups received:

  • 2 Advil® + 2 Extra-Strength Tylenol® (Ibuprofen 400mg + Acetaminophen 1000mg)
  • 1 Percocet® (Oxycodone 5mg + Acetaminophen 325mg)
  • 1 Vicodin® (Hydrocodone 5mg + Acetaminophen 300mg)
  • 1 Tylenol #3® (Codeine 30mg + Acetaminophen 300mg)

The baseline Pain Score was 8.7 across all groups. At 2 hours, both the non-opioid group and the Percocet® group improved by 50% (Pain Score 4.3-4.4). The other 2 groups had slightly less improvement, with Vicodin® at 40% and Tylenol #3® at 45% pain reduction.

The authors conclude, “there were no statistically significant or clinically important differences in pain reduction at 2 hours among single-dose treatment with ibuprofen and acetaminophen or with 3 different opioid and acetaminophen combination analgesics.”

This study shows that adequate acute pain control can be achieved in the ED without use of opioids for certain painful injuries.

Final Thoughts:

While important, I consider the study incomplete because the dose of acetaminophen in the opioid groups is insufficient and not consistent with that of the ibuprofen group. A single regular Tylenol® contains 325mg, and the recommended dose is 650mg. With extra-strength, the dose would be 1000mg. Each of the opioid groups had the recommended dose of opioids, but not the recommended dose of acetaminophen, and not the dose provided with the ibuprofen group.

In my practice, I would always prescribe 2 tabs of Tylenol #2® instead of 1 tab of Tylenol #3®. In that way, my patients received the same opioid dose, but with the recommended acetaminophen dose.

It is possible that with the addition of 675-700mg more acetaminophen, that opioid pain relief would have been superior to the ibuprofen group. However, this is a small point in an otherwise very important study.