Written by Clay Smith
Spoon Feed
For adults with severe pain in the ED, IV hydromorphone provided significantly better pain control than IV acetaminophen (APAP) but resulted in more nausea and vomiting.
Why does this matter?
There is a move to use non-opiates for pain in the ED. But do they work? Prior studies have shown lackluster results. For example, IV APAP was no better than oral. A Cochrane review found it reduced post-op pain more than placebo, but few studies compared it with an opiate.
You’ll never guess if hydromorphone or acetaminophen was better
This was a double-blinded RCT in 206 adults in the ED with severe pain who were randomized to receive either hydromorphone 1mg or APAP 1g IV. At 60 minutes, pain on a 0 to 10 scale dropped 5.3 points for hydromorphone and only 3.3 points for APAP. The downside is more patients had nausea/vomiting with hydromorphone. It is notable that IV APAP also reduced pain, although it’s expensive and less effective. It has this going for it – at least patients won’t feel nauseated.
Another Spoonful
See this WaPo take on The growing case against IV APAP.
Source
Randomized Controlled Trial of Intravenous Acetaminophen Versus Intravenous Hydromorphone for the Treatment of Acute Pain in the Emergency Department. Ann Emerg Med. 2018 Aug 14. pii: S0196-0644(18)30550-X. doi: 10.1016/j.annemergmed.2018.06.019. [Epub ahead of print]
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Reviewed by Thomas Davis
Worth recognizing 3 points out of 10 is still a significant reduction in pain, and might make the difference between giving 2mg of hydromorphone vs 1mg after the APAP.
Of course, it’s moot for me since I don’t even know if we have iv APAP in Canada-I’ve certainly never been able to order it. We use a boatload of iv ketorolac for pain here…
APAP did reduce pain. And prior Cochrane review shows it does so better than placebo. So it may have a minor role.
Slower administration of the Morphine (over 30 sec) seems to show a significant decrease in N&V in my experience
Maybe IV APAP only decreases pain by 3 points. I’d take that and the huge decrease in opioid abuse if it meant we would see a decrease in the number of drug seekers, addicts, and overdoses. Perhaps IV APAP and ketorolac (unless contraindicated of course) together would be more effective.
APAP definitely helped. I guess my take home is that for severe pain, hydromorphone is clearly better. From what I read, IV APAP is also extremely expensive. So, EDs will have to weigh the pros and cons.