Written by Caitlin Nicholson
Opioids, other than codeine, were found to be more effective when compared to non-opioids for treatment of acute musculoskeletal pain after ED discharge. However, they were also associated with a higher rate of adverse outcomes.
Pain, pain go away…
This prospective meta-analysis included 6 randomized controlled trials designed to evaluate efficacy of relief of acute musculoskeletal pain in patients discharged from the ED. The studies were done in the U.S. or Canada and 4 included adults only, while the remaining 2 included pediatric patients, for a total of 1,161 participants. Amongst the 6 studies, codeine, hydrocodone, morphine, and oxycodone were used. Acetaminophen was always found in the opioid arm, except in the studies that used morphine. The NSAIDs used included ketorolac, ibuprofen, and naproxen.
The primary outcome measured was the difference in pain intensity scores or pain relief between the two treatment options any time after an ED visit for acute musculoskeletal pain. Secondary outcomes included adverse events and patients requiring rescue analgesics. Of the six studies reviewed, 5 did not show a difference in efficacy between opioids and NSAIDs, and one reported better pain relief for the opioid group compared to placebo. While the primary outcome concluded that there was no benefit to prescribing opioids compared to non-opioids, a sensitivity analysis showed that when comparing opioids other than codeine to non-opioids, opioids provided better pain relief. All six of the studies reported a higher incidence of adverse events in the opioid group.
The study was limited by variability in prescribing practices; a variety of opioids and non-opioid medications were used in each of the studies, and there was little consistency in dosing. Other limitations included study population heterogeneity, type of pain, and follow-up duration.
How will this change my practice?
As we slowly attempt to back our way out of the opioid crisis, there is a lack of clarity regarding short-term opiate prescribing from the ED. I already attempt to limit opiate use for pain control, especially when patients are being discharged, and will continue to do so. While the outcome of this study may have been clouded by the poor analgesic effects of codeine, there were more adverse outcomes in the opioid group than the non-opioid group. Ultimately, more quality research is needed to optimize short-term pain control for patients who are discharged from the ED.
Efficacy of prescribed opioids for acute pain after being discharged from the emergency department: A systematic review and meta-analysis. Acad Emerg Med. 2023 Aug 22. doi: 10.1111/acem.14790. Online ahead of print.