Are ibuprofen plus acetaminophen as good as opioids in treating acute extremity pain

November 22, 2017, 3:19 pm


Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial. Chang AK et al. JAMA 2017;318:1661-1667.


As Dr. Demetrios Kyriacou points out in a must-read editorial accompanying this paper, a growing body of evidence clearly indicates that even short-term opioid use for painful injuries or procedures carries a significant risk of leading to chronic use and potential abuse. We are now realizing the importance of avoiding even limited use of drugs such as oxycodone and hydrocodone in opioid-naive patients, if at all possible.

The authors carried out randomized double-blind trial in adult patients in the emergency department for acute extremity pain who were scheduled to have the area x-rayed. These patients received one of four oral analgesic regimens:

  1. ibuprofen 400-mg + acetaminophen 1000-mg
  2. oxycodone 5 mg + acetaminophen 325-mg
  3. hydrocodone 5-mg + acetaminophen 300-mg
  4. codeine 30-mg + acetaminophen 300-mg

The study was done in 2 EDs in the Montefiore Medical System in The Bronx, NY. Patients rated their pain on an 11-point Numeric Rating Scale immediately before analgesics were given and again 1-hour and 2-hours later. A clinically significant difference in pain score was pre-defined as 1.3 points on the NRS scale, based on previous literature. The primary outcome was a between-group difference in pain score decrease at 2 hours. (Interestingly, for reasons not explained in the paper, the proposed primary outcome when the study was listed at was pain difference at 1 hour.)

The study enrolled 411 patients. There was no statistically or clinically significant difference between the groups as to pain relief at 1- or 2-hours, and no difference in need to administer rescue analgesics.

There are a number of limitations to this study, many of which the authors discuss. Observation time was limited to 2 hours, and adverse effects were not analyzed. In addition, the dosing seems somewhat arbitrary to me. The 3 regimens including opioids were dosed on the low side both as to the opioid and acetaminophen. By the way, combination products such as Vicodin or Percoset never made sense to me, since the formulations do not contain an effective analgesic dose of acetaminophen.

Because of these limitations, the authors’ conclusion is rather weak:

For patients presenting to the ED with acute extremity pain, 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. Further research to assess adverse events and other dosing may be warranted.

However, the paper and Dr. Kyriacou’s editorial does spur thought about how to minimize use of opioids in treating specific types of acute pain.


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