People experience and seek treatment for pain for many reasons. With the opioid epidemic still a major concern in the healthcare community, providers are balancing the need to decrease pain levels with the risks and benefits of various treatment options. Since even short-term opioid use can be a risk factor for long term dependence, having clinically proven alternatives available to patients is imperative for reducing the number of prescribed opioids.
Emergency room providers see countless patients with complaints of severe pain. The Emergency Department (ED) cares for a variety of causes and anatomical locations of pain. From broken arms and legs, to motor vehicle crash injuries, from food poisoning to appendicitis, from kitchen cuts to mechanical mishaps involving burns or crushed extremities, the ED sees a little bit of everything.
It is also common for ED patients in moderate to severe pain to be given some form of pain relief while the providers are running tests and while waiting for additional treatment. Researchers evaluating results of pain relief options in an effort to help find the most effective with the least risks, noted that opioids are a common first-line treatment for pain in EDs, and decided to use this setting to compare 4 different drug combinations as treatments for pain. Their findings were published in the November, 2017 Journal of the American Medical Association.
Study participants were individuals who sought care at one of 2 participating urban EDs in New York. Patients had complaints of extremity pain and had clinical reason for the ED attending provider to request radiology imaging. The delay involved with completing the imaging provided a 1-2 hour delay for the pain relief to be measured. Additionally, this culled the participants to a group that were experiencing a seemingly more severe condition where it would be more likely that they would be prescribed opioids.
Patients rated their pain level immediately before taking pain medication, as well as 1 hour and 2 hours after the medication was administered. Patients were given one of 4 drug combinations:
- 400 mg of ibuprofen and 1000 mg of acetaminophen
- 5 mg of oxycodone and 325 mg of acetaminophen
- 5 mg of hydrocodone and 300 mg of acetaminophen
- 30 mg of codeine and 300 mg of acetaminophen.
Pain levels prior to taking medication was initially high across the board, and decreased in all groups over time. What some may find surprising is that the non-opioid combination was as effective as the opioid! Further, the non-opioid treatment was actually slightly more effective than 2 of the opioid combinations!
The commonly used criterion for studies such as this, is that there should be a 1.3 or larger difference to be considered “clinically important.” Pain scores were decreased:
- by 4.3 (95% CI, 3.6 to 4.9) in the ibuprofen and acetaminophen group
- by 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
- by 3.9 (95% CI, 3.2 to 4.5) in the codeine and acetaminophen group.
At the 2-hour mark, when there was the largest difference between groups, the maximum difference was still only 0.9.
The researchers concluded, “The findings support the inference that there are no clinically meaningful differences between the analgesic effects of these 4 analgesics and suggest that a combination of ibuprofen and acetaminophen represents an alternative to oral opioid analgesics for the treatment of acute extremity pain in the ED.” Further, when comparing their results to other studies that have been completed, they suggest that these results may “generalize beyond the treatment of acute extremity pain.”
If you are experiencing pain, consider your options before deciding on a treatment. Could this pain be treated with non-pharmacological methods? Have you tried cold/hot packs? If the pain is musculoskeletal, have you seen your chiropractor? What about acupuncture? Always discuss non-opioid analgesics with your prescribing doctor before moving on to riskier medications. If you do require opioids, ask about the plan to reduce them as quickly as possible. Even when recovering from surgery, some patients find they are able to manage pain with non-opioids after only a day or two, especially for more minor procedures. While you shouldn’t have to suffer in pain, there are options available that may give you relief, without unnecessary side effects.
Talk to your doctor of chiropractic about the treatments they provide for pain relief. Research shows that in many cases, chiropractic can reduce or even eliminate the need for pharmaceutical analgesics. If you don’t have a chiropractor, find a TCA member doctor near you at www.tnchiro.com/find-a-doctor.
Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial. JAMA.2017;318(17):1661–1667. doi:10.1001/jama.2017.16190
Research: Chiropractic Effectively Reduces Opioid Usage Feb. 26, 2019 www.tnchiro.com/news/research-chiropractic-effectively-reduces-opioid-usage/