No Significant Difference in Pain Relief for Opioids vs Non-Opioid Analgesics for Treating Arm or Leg Pain

Bottom Line: For adults coming to the emergency department for arm or leg pain due to sprain, strain, or fracture, there was no difference in pain reduction after 2 hours with ibuprofen-acetaminophen vs three comparison opioid-acetaminophen (paracetamol) combinations.
Why The Research Is Interesting: The United States is facing an opioid epidemic with almost 500,000 individuals dying from opioid overdoses since 2000. Despite the epidemic, opioid analgesics remain a first-line treatment for moderate to severe acute pain in the emergency department. The combination of ibuprofen and acetaminophen may represent an effective non-opioid alternative.
Who: 416 patients (ages 21 to 64 years) with moderate to severe acute extremity pain in two urban emergency departments were randomly assigned to receive
— 400 mg ibuprofen and 1,000 mg acetaminophen
—  5 mg oxycodone and 325 mg acetaminophen
— 5 mg hydrocodone and 300 mg acetaminophen; or
— 30 mg codeine and 300 mg acetaminophen
When: July 2015 to August 2016
What (Study Measures): The between-group difference in decline in pain two hours after taking the study drugs.
How (Study Design): This was a randomized clinical trial (RCT). Randomized trials allow for the strongest inferences to be made about the true effect of an intervention such as a medication or a procedure. However, not all RCT results can be replicated because patient characteristics or other variables in real-world settings may differ from those that were studied in the RCT.
Authors: Andrew K. Chang, M.D., M.S., of Albany Medical College, Albany, New York, and coauthors
Results: After 2 hours pain was less in all participants, without any important difference in effect between the four groups.
Study Limitations: The results apply only to pain after two hours. About 1 in 5 patients required additional medication to control their pain.
Study Conclusions: There were no important differences in pain reduction after 2 hours with ibuprofen-acetaminophen or opioid-acetaminophen combination pills in emergency department patients with acute extremity pain. The findings suggest that ibuprofen-acetaminophen is a reasonable alternative to opioid management of acute extremity pain due to sprain, strain, or fracture, but further research to assess longer-term effect, adverse events and dosing is warranted.
Related material:
The following related elements also are available on the For The Media website:
The editorial, “Opioid vs Nonopioid Acute Pain Management in the Emergency Department,” by Demetrios N. Kyriacou, M.D., Ph.D., Senior Editor, JAMA, Chicago; Northwestern University Feinberg School of Medicine, Chicago.
For more details and to read the full study, please visit the For The Media website.