Address notion of opioid superiority

codeine tabsules spill from orange pill bottle

Ibuprofen and paracetamol works just as well as opioid combinations for breaks and sprains, emergency doctors say

US emergency department doctors have found that a one-two combination of ibuprofen with paracetamol works as well as a one-two combination of any of three different opioids with paracetamol in reducing pain brought on from a sprain, strain or fracture in the arms or legs.

And addressing the idea that opioids are superior could help reduce the US opioid crisis, one stakeholder says.

The study, published in JAMA this week, saw 416 patients aged 21 to 64 years with moderate-to-severe acute extremity pain, randomly assigned to receive one of several treatments.

These included:

  • 400mg ibuprofen and 1000mg of acetaminophen (paracetamol);
  • 5mg oxycodone and 325mg of acetaminophen;
  • 5mg hydrocodone and 300mg of acetaminophen; or
  • 30mg codeine and 300mg of acetaminophen.

The primary outcome was the between-group difference in pain reduction two hours after taking the medication, the authors write.

Pain intensity was assessed using the 11-point numerical rating scale.

“At two hours, the mean NRS pain score decreased by 4.3 (95%CI, 3.6 to 4.9) in the ibuprofen and acetaminophen group; by 4.4 (95%CI, 3.7 to 5.0) in the oxycodone and acetaminophen group; by 3.5 (95%CI, 2.9 to 4.2) in the hydrocodone and acetaminophen group; and by 3.9 (95%CI, 3.2 to 4.5) in the codeine and acetaminophen group (P = .053),” the authors write.

“The largest difference in decline in the NRS pain score from baseline to two hours was between the oxycodone and acetaminophen group and the hydrocodone and acetaminophen group (0.9; 99.2%CI, −0.1 to 1.8), which was less than the minimum clinically important difference in NRS pain score of 1.3.”

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, the authors say.

An accompanying editorial suggests that reducing the notion that opioids are better treatment for pain could help to stem the opioid addiction crisis in the US.

“The United States is experiencing a serious epidemic of opioid related drug addiction that includes a 200% increase in the numberof opioid-related overdose deaths from 2000 to 2014,” writes Demetrios N Kyriacou, from the Northwestern University Feinberg School of Medicine in Chicago.

“Long-term opioid use often begins with the treatment of acute pain using a prescription opioid medication. Recent studies from different clinical settings have demonstrated persistent opioid use among initially opioid-naive patients who were treated for short-term conditions that did not require long term pain management.

“In particular, the likelihood of long-term opioid use increases with greater prescribed cumulative doses, and with each additional day of prescribed opioid medication beyond the third day.”

“Patients with moderate to severe pain are often sent home with a prescription for an opioid medication if they were successfully treated with an opioid medication in the ED. In addition, the proportion of adult ED patients prescribed an opioid medication has increased significantly during the current opioid epidemic.”

Dr Kyriacou cites a recent study which found that among opioid-naive ED patients in Colorado who filled an opioid prescription for a mild-to-moderate acute pain condition (such as abdominal, back, pelvic, chest, dental, extremity, head or neck pain) that was not expected to result in recurrent chronic pain, 17% were still taking an opioid medication a year after their initial ED evaluation.

As well as other strategies, the US opioid addiction crisis could be addressed by “re-examination of the long-standing assumptions that opioids are superior to non-opioids in most clinical situations requiring management of moderate to severe pain,” he writes.

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