Nonopioids as effective for acute extremity pain, study says

No statistically significant differences found in pain reduction between treatment groups

Amid the proverbial opioid crisis, emergency department (ED) clinicians continuously seek evidence-based alternatives for analgesia. In a double-blind, randomized, controlled trial published in JAMA last November, Chang and colleagues suggested that a nonopioid alternative may be just as efficacious as three opioid-containing regimens for treating acute extremity pain in the ED.

“The opioid crisis continues to affect our society every day, and it is getting bigger and more severe. Since 2015, there has been a staggering 17% increase in number of deaths caused by drug overdose,” said Billy Sin, PharmD, MBA, BCPS, assistant professor of pharmacy practice at Long Island University’s Arnold and Marie Schwartz College of Pharmacy and Health Sciences and director of the emergency medicine clinical research program at The Brooklyn Hospital Center.

According to the National Institutes of Health, approximately 90 Americans die of an opioid overdose every day. The economic burden attributed from lost productivity, costs of medical treatments, and legal enforcement amounts to $78.5 billion annually.

Investigators compared the efficacy of a nonopioid oral analgesic regimen with three opioid-containing combinations in 416 patients at the Montefiore Medical Center in Bronx, NY. Participants presented to the ED with moderate to severe acute extremity pain due to sprain, strain, or fracture. The four study treatment regimens included the following:

  • Ibuprofen 400 mg plus acetaminophen 1,000 mg
  • Oxycodone 5 mg plus acetaminophen 325 mg
  • Hydrocodone 5 mg plus acetaminophen 300 mg
  • Codeine 30 mg plus acetaminophen 300 mg

Pain was measured on an 11-point numeric rating scale before and 2 hours after administration of analgesics. The mean pain score before administration was 8.7 among 411 qualifying participants. At 2 hours, reductions in pain scores ranged from 4.4 points in the oxycodone plus acetaminophen group to 3.5 in the hydrocodone and acetaminophen group. No statistically significant differences were found in pain reduction between treatment groups.

Limitations of this study included its lack of adverse event data. Also, while authors noted that it is unknown whether the duration of analgesia differs among the study drugs, their onsets of action range from 10 to 60 minutes, and they may have differing times to maximum effect. Use of a 2-hour endpoint marker does not take this pharmacokinetic information into account.

Sin pointed out that while post-hoc analyses adjusted for patients’ use of rescue analgesics, “it is important to note that the process is based on assumptions about the data. Hence, it is hard to say whether the process may have driven the results toward the null.”

Approach with caution. Opioids and nonopioid analgesics like those studied in the cited literature are first-line options for acute pain control in EDs. However, even short-term opioid use may confer a predisposition to opioid dependence, according to the study. Effective pain management in the ED requires proper clinical management and responsible prescribing and dispensing.

For the full article, please visit for the February 2018 issue of Pharmacy Today.