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Fink PB, Wheeler AR, Smith WR, Brant-Zawadzki G, Lieberman JR, McIntosh SE, Van Tilburg C, Wedmore IS, Windsor JS, Hofmeyr R, Weber D. Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update. Wilderness Environ Med 2024; 35:198-218. [PMID: 38651342 DOI: 10.1177/10806032241248422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
The Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an update of the 2014 version of the "WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments" published in Wilderness & Environmental Medicine 2014; 25:41-49.
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Affiliation(s)
- Patrick B Fink
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT
| | - Albert R Wheeler
- Department of Emergency Medicine, St. John's Health, Jackson, WY
| | - William R Smith
- Department of Emergency Medicine, St. John's Health, Jackson, WY
| | | | | | - Scott E McIntosh
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT
| | | | - Ian S Wedmore
- Uniformed Services University of the Health Sciences, Bethesda, MD
| | | | - Ross Hofmeyr
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - David Weber
- Mountain Rescue Collective, LLC, Park City, UT
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Jones CMP, Langford A, Maher CG, Abdel Shaheed C, Day R, Lin CWC. Opioids for Acute Musculoskeletal Pain: A Systematic Review with Meta-Analysis. Drugs 2024; 84:305-317. [PMID: 38451443 PMCID: PMC10982090 DOI: 10.1007/s40265-024-01999-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE To evaluate the efficacy of opioids for people with acute musculoskeletal pain against placebo. STUDY DESIGN Systematic review and meta-analyses of randomised, placebo-controlled trials of opioid analgesics for acute musculoskeletal pain in any setting. The primary outcomes were pain and disability at the immediate timepoint (< 24 h). DATA SOURCES Multiple databases were searched from their inception to February 22nd, 2023. DATA SYNTHESIS Continuous outcomes were converted to a 0-100 scale. Dichotomous outcomes were presented as risk differences. Risk of bias and certainty of evidence was assessed. RESULTS We located 17 trials (1 intravenous and 16 oral route of administration). For adults, high certainty evidence from 11 comparisons shows that oral opioids provide small benefits relative to placebo in the immediate term for pain (mean difference [MD] - 8.8 95% confidence interval [CI] - 12.0 to - 5.6). For disability, the difference is uncertain (MD - 6.2, 95% CI - 17.8 to 5.4). Opioid groups were at higher risk of adverse events (MD 14.3%, 95% CI 8.3-20.4%, very low certainty). There was moderate certainty evidence of a large effect of IV morphine on sciatica pain (MD -42.5, 95% CI - 49.9 to - 35.1, n = 197, 1 study). In paediatric populations, moderate certainty evidence from 3 trials shows that oral opioids probably do not provide benefit beyond that of placebo for pain (MD 6.1, 95% CI - 1.7 to 12.8) and there was no evidence for disability. There was low certainty evidence that there may be no difference in adverse events (MD 10.4%, 95% CI - 0.6 to 21.4%). DISCUSSION Intravenous morphine likely offers benefits, but oral opioids may not provide clinically meaningful benefits. PROSPERO REGISTRATION CRD42021249346.
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Affiliation(s)
- Caitlin M P Jones
- Sydney Musculoskeletal Health, Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.
- , Level 10N KGV Building, Missenden Road, Camperdown, NSW, 2050, Australia.
| | - Aili Langford
- School of Pharmacy, The University of Sydney and the Centre for Medicine Use and Safety, Monash University, Melbourne, Australia
| | - Chris G Maher
- Sydney Musculoskeletal Health, Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Christina Abdel Shaheed
- Sydney Musculoskeletal Health, Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Richard Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney and St Vincent's Clinical Campus, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Chung-Wei Christine Lin
- Sydney Musculoskeletal Health, Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
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Chen Q, Maher CG, Han CS, Abdel Shaheed C, Lin CWC, Rogan EM, Machado GC. Continued Opioid Use and Adverse Events Following Provision of Opioids for Musculoskeletal Pain in the Emergency Department: A Systematic Review and Meta-Analysis. Drugs 2023; 83:1523-1535. [PMID: 37768540 PMCID: PMC10624756 DOI: 10.1007/s40265-023-01941-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND The prevalence of continued opioid use or serious adverse events (SAEs) following opioid therapy in the emergency department (ED) for musculoskeletal pain is unclear. The aim of this review was to examine the prevalence of continued opioid use and serious adverse events (SAEs) following the provision of opioids for musculoskeletal pain in the emergency department (ED) or at discharge. METHODS Records were searched from MEDLINE, EMBASE and CINAHL from inception to 7 October 2022. We included randomised controlled trials and observational studies enrolling adult patients with musculoskeletal pain who were administered and/or prescribed opioids in the ED. Continued opioid use and opioid misuse data after day 4 since ED discharge were extracted. Adverse events were coded using the Common Terminology Criteria for Adverse Events (CTCAE), and those rated as grades 3-4 (severe or life-threatening) and grade 5 (death) were considered SAEs. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. RESULTS Seventy-two studies were included. Among opioid-naïve patients who received an opioid prescription, 6.8-7.0% reported recent opioid use at 3-12 months after discharge, 4.4% filled ≥ 5 opioid prescriptions and 3.1% filled > 90-day supply of opioids within 6 months. The prevalence of SAEs was 0.02% [95% confidence interval (CI) 0, 0.2%] in the ED and 0.1% (95% CI 0, 1.5%) within 2 days. One study observed 42.9% of patients misused opioids within 30 days after discharge. CONCLUSIONS Around 7% of opioid-naïve patients with musculoskeletal pain receiving opioid therapy continue opioid use at 3-12 months after ED discharge. SAEs following ED administration of an opioid were uncommon; however, studies only monitored patients for 2 days. PROTOCOL REGISTRATION 10.31219/osf.io/w4z3u.
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Affiliation(s)
- Qiuzhe Chen
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia.
| | - Chris G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| | - Christopher S Han
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| | - Eileen M Rogan
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
- Emergency Department, Canterbury Hospital, Campsie, NSW, Australia
| | - Gustavo C Machado
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
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Mitra B, Roman C, Wu B, Luckhoff C, Goubrial D, Amos T, Bannon-Murphy H, Huynh R, Dooley M, Smit DV, Cameron PA. Restriction of oxycodone in the emergency department (ROXY-ED): A randomised controlled trial. Br J Pain 2023; 17:491-500. [PMID: 38107754 PMCID: PMC10722107 DOI: 10.1177/20494637231189031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
Background The prescription of opioids in emergency care has been associated with harm, including overdose and dependence. The aim of this trial was to assess restriction of access to oxycodone (ROXY), in combination with education and guideline modifications, versus education and guideline modifications alone (standard care) to reduce oxycodone administration in the Emergency Department (ED). Methods An unblinded, active control, randomised controlled trial was conducted in an adult tertiary ED. Participants were patients aged 18-75 years who had analgesics administered in the ED. The primary intervention was ROXY, through removal of all oxycodone immediate release tablets from the ED imprest, with availability of a small supply after senior clinician approval. The intervention did not restrict prescription of discharge medications. The primary outcome measure was oxycodone administration rates. Secondary outcomes were administration rates of other analgesic medications, time to initial analgesics and oxycodone prescription on discharge. Results There were 2258 patients eligible for analysis. Oxycodone was administered to 80 (6.1%) patients in the ROXY group and 221 (23.3%) patients in the standard care group (relative risk (RR) 0.26; 95% CI: 0.21 to 0.33; p < .001). Tapentadol was prescribed more frequently in the ROXY group (RR 2.17; 95% CI: 1.71-2.74), while there were no differences in prescription of other analgesic medications. On discharge, significantly fewer patients were prescribed oxycodone (RR 0.51; 95% CI: 0.39-0.66) and no differences were observed in prescription rates of other analgesic medications. There was no difference in time to first analgesic (HR 0.94; 95% CI: 0.86-1.02). Conclusions Restricted access to oxycodone was superior to education and guideline modifications alone for reducing oxycodone use in the ED and reducing discharge prescriptions of oxycodone from the ED. The addition of simple restrictive interventions is recommended to enable rapid changes to clinician behaviour to reduce the potential harm associated with the prescribing of oxycodone in the ED.
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Affiliation(s)
- Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Cristina Roman
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- Pharmacy Department, Alfred Health, Melbourne, VIC, Australia
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Bertha Wu
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - Carl Luckhoff
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - Diana Goubrial
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- Pharmacy Department, Alfred Health, Melbourne, VIC, Australia
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Timothy Amos
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | | | - Ronald Huynh
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - Michael Dooley
- Pharmacy Department, Alfred Health, Melbourne, VIC, Australia
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - De Villiers Smit
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Peter A. Cameron
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Jones CMP, Lin CWC, Jamshidi M, Abdel Shaheed C, Maher CG, Harris IA, Patanwala AE, Dinh M, Mathieson S. Effectiveness of Opioid Analgesic Medicines Prescribed in or at Discharge From Emergency Departments for Musculoskeletal Pain : A Systematic Review and Meta-analysis. Ann Intern Med 2022; 175:1572-1581. [PMID: 36252245 DOI: 10.7326/m22-2162] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The comparative benefits and harms of opioids for musculoskeletal pain in the emergency department (ED) are uncertain. PURPOSE To evaluate the comparative effectiveness and harms of opioids for musculoskeletal pain in the ED setting. DATA SOURCES Electronic databases and registries from inception to 7 February 2022. STUDY SELECTION Randomized controlled trials of any opioid analgesic compared with placebo or a nonopioid analgesic administered or prescribed to adults in or on discharge from the ED. DATA EXTRACTION Pain and disability were rated on a scale of 0 to 100 and pooled using a random-effects model. Certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. DATA SYNTHESIS Forty-two articles were included (n = 6128). In the ED, opioids were statistically but not clinically more effective in reducing pain in the short term (about 2 hours) than placebo and paracetamol (acetaminophen) but were not clinically or statistically more effective than nonsteroidal anti-inflammatory drugs (NSAIDs) or local or systemic anesthetics. Opioids may carry higher risk for harms than placebo, paracetamol, or NSAIDs, although evidence is very uncertain. There was no evidence of difference in harms associated with local or systemic anesthetics. LIMITATIONS Low or very low GRADE ratings for some outcomes, unexplained heterogeneity, and little information on long-term outcomes. CONCLUSION The risk-benefit balance of opioids versus placebo, paracetamol, NSAIDs, and local or systemic anesthetics is uncertain. Opioids may have equivalent pain outcomes compared with NSAIDs, but evidence on comparisons of harms is very uncertain and heterogeneous. Although factors such as route of administration or dosage may explain some heterogeneity, more work is needed to identify which subgroups will have a more favorable benefit-risk balance for one analgesic over another. Longer-term pain management once dose thresholds are reached is also uncertain. PRIMARY FUNDING SOURCE None. (PROSPERO: CRD42021275293).
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Affiliation(s)
- Caitlin M P Jones
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Masoud Jamshidi
- Department of Sports Physiology, University of Tehran, Tehran, Iran (M.J.)
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Ian A Harris
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW Sydney, Sydney, New South Wales, Australia (I.A.H.)
| | - Asad E Patanwala
- Royal Prince Alfred Hospital, and School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia (A.E.P.)
| | - Michael Dinh
- Sydney Local Health District and The University of Sydney, Sydney, New South Wales, Australia (M.D.)
| | - Stephanie Mathieson
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
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Feldman CA, Fredericks-Younger J, Lu SE, Desjardins PJ, Malmstrom H, Miloro M, Warburton G, Ward B, Ziccardi V, Fine D. The Opioid Analgesic Reduction Study (OARS)-a comparison of opioid vs. non-opioid combination analgesics for management of post-surgical pain: a double-blind randomized clinical trial. Trials 2022; 23:160. [PMID: 35177108 PMCID: PMC8851821 DOI: 10.1186/s13063-022-06064-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 01/29/2022] [Indexed: 12/01/2022] Open
Abstract
Background Everyday people die unnecessarily from opioid overdose-related addiction. Dentists are among the leading prescribers of opioid analgesics. Opioid-seeking behaviors have been linked to receipt of initial opioid prescriptions following the common dental procedure of third molar extraction. With each opioid prescription, a patient’s risk for opioid misuse or abuse increases. With an estimated 56 million tablets of 5 mg hydrocodone annually prescribed after third molar extractions in the USA, 3.5 million young adults may be unnecessarily exposed to opioids by dentists who are inadvertently increasing their patient’s risk for addiction. Methods A double-blind, stratified randomized, multi-center clinical trial has been designed to evaluate whether a combination of over-the-counter non-opioid-containing analgesics is not inferior to the most prescribed opioid analgesic. The impacted 3rd molar extraction model is being used due to the predictable severity of the post-operative pain and generalizability of results. Within each site/clinic and gender type (male/female), patients are randomized to receive either OPIOID (hydrocodone/acetaminophen 5/300 mg) or NON-OPIOID (ibuprofen/acetaminophen 400/500 mg). Outcome data include pain levels, adverse events, overall patient satisfaction, ability to sleep, and ability to perform daily functions. To develop clinical guidelines and a clinical decision-making tool, pain management, extraction difficulty, and the number of tablets taken are being collected, enabling an experimental decision-making tool to be developed. Discussion The proposed methods address the shortcomings of other analgesic studies. Although prior studies have tested short-term effects of single doses of pain medications, patients and their dentists are interested in managing pain for the entire post-operative period, not just the first 12 h. After surgery, patients expect to be able to perform normal daily functions without feeling nauseous or dizzy and they desire a restful sleep at night. Parents of young people are concerned with the risks of opioid use and misuse, related either to treatments received or to subsequent use of leftover pills. Upon successful completion of this clinical trial, dentists, patients, and their families will be better able to make informed decisions regarding post-operative pain management. Trial registration ClinicalTrials.govNCT04452344. Registered on June 20, 2020
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Affiliation(s)
- Cecile A Feldman
- School of Dental Medicine, Rutgers University, 110 Bergen Street, Newark, NJ, 07103, USA. .,School of Public Health, Rutgers University, 683 Hoes Lane, Piscataway, NJ, 08854, USA.
| | | | - Shou-En Lu
- School of Public Health, Rutgers University, 683 Hoes Lane, Piscataway, NJ, 08854, USA
| | - Paul J Desjardins
- School of Dental Medicine, Rutgers University, 110 Bergen Street, Newark, NJ, 07103, USA
| | - Hans Malmstrom
- Eastman Institute for Oral Health, University of Rochester, 625 Elmwood Ave, Rochester, NY, 14620, USA
| | - Michael Miloro
- College of Dentistry, University of Illinois, 801 S Paulina St, Room 110 (MC 835), Chicago, IL, 60612, USA
| | - Gary Warburton
- School of Dentistry, University of Maryland, 650 W Baltimore St, Room 1209, Baltimore, MD, 2120, USA
| | - Brent Ward
- School of Dentistry, University of Michigan, 1515 E. Hospital Drive, Ann Arbor, MI, 48109, USA
| | - Vincent Ziccardi
- School of Dental Medicine, Rutgers University, 110 Bergen Street, Newark, NJ, 07103, USA
| | - Daniel Fine
- School of Dental Medicine, Rutgers University, 110 Bergen Street, Newark, NJ, 07103, USA
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Friedman BW, Irizarry E, Feliciano C, Izzo AJ, Borrayes L, Restivo A, Costa V, Bijur PE. A randomized controlled trial of oxycodone/acetaminophen versus acetaminophen alone for emergency department patients with musculoskeletal pain refractory to ibuprofen. Acad Emerg Med 2021; 28:859-865. [PMID: 33576545 DOI: 10.1111/acem.14231] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/07/2021] [Accepted: 02/09/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Use of oral opioids does not result in more pain relief than nonopioid alternatives when administered to patients as first-line treatment for acute musculoskeletal pain. This study compared the efficacy of oxycodone/acetaminophen to that of acetaminophen alone as second-line treatment for patients with acute musculoskeletal pain who were administered prescription-strength ibuprofen and reported insufficient relief 1 h later. METHODS A randomized, double-blind study was conducted in two urban emergency departments. Opioid-naïve patients ≥ 18 years with an acute musculoskeletal injury were administered ibuprofen 600 mg as part of the study protocol. Those who reported insufficient relief 1 h later were randomized (1:1 ratio) to oxycodone 10 mg/acetaminophen 650 mg or acetaminophen 650 mg. The primary outcome was improvement in 0 to 10 pain scale between randomization and 2 h later. We also assessed medication-associated adverse events. A sample size calculation, built around a minimum clinically important difference of 1.3 units, determined the need for 154 patients. RESULTS We screened 924 patients and enrolled 393. All 393 received ibuprofen. A total of 159 (40%) patients reported inadequate relief after 1 h had elapsed. A total of 154 of these were randomized, 77 to oxycodone/acetaminophen and 77 to acetaminophen. Baseline characteristics were comparable. Among patients randomized to oxycodone/acetaminophen, mean (±SD) improvement in 0 to 10 pain scale was 4.0 (±2.6) versus 2.9 (±2.4) in the acetaminophen arm. The 95% confidence interval (CI) for the mean difference of 1.1 was 0.3 to 1.9. Among patients who received oxycodone/acetaminophen, 26 of 76 (34%) reported any medication-related adverse event versus seven of 74 (9%) participants who received acetaminophen. The 95% CI for the between-group difference of 25% was 12% to 37%). CONCLUSION Among patients with acute musculoskeletal pain refractory to oral ibuprofen, oxycodone/acetaminophen resulted in slightly greater pain relief than acetaminophen, but this was associated with more medication-related adverse events.
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Affiliation(s)
- Benjamin W. Friedman
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Eddie Irizarry
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Carmen Feliciano
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Albert J. Izzo
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Lester Borrayes
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Andrew Restivo
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Vincent Costa
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Polly E. Bijur
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
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Donthula D, Conner CR, Truong VTT, Green C, Jiang C, Wandling MW, Komak S, Huzar TF, Adams SD, Freet DJ, Wainwright DJ, Wade CE, Kao LS, Harvin JA. Impact of Opioid-Minimizing Pain Protocols after Burn Injury. J Burn Care Res 2021; 42:1146-1151. [PMID: 34302482 DOI: 10.1093/jbcr/irab143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In 2019, we implemented a pill-based, opioid-minimizing pain protocol and protocolized moderate sedation for dressing changes in order to decrease opioid exposure in burn patients. We hypothesized that these interventions would reduce inpatient opioid exposure without increasing acute pain scores. Two groups of consecutive patients admitted to the burn service were compared: Pre (01/01/2018 to 07/31/2019) and Post (01/01/2020 to 06/30/2020) implementation of the protocols (08/01/2019 to 12/31/2019). We abstracted patient demographics and burn injury characteristics from the burn registry. We obtained opioid exposure and pain scale scores from the electronic medical record. The primary outcome was total morphine milligram equivalents (MME). Secondary outcomes included MME/day, pain domain-specific MME, and pain scores. Pain was estimated by creating a normalized pain score (range 0-1), which incorporated 3 different pain scales (Numeric Rating Scale, Behavioral Pain Scale, and Behavioral Pain Assessment Scale). Groups were compared using Wilcoxon Rank Sum and Chi Square. Treatment effects were estimated using Bayesian generalized linear models.There were no differences in demographics or burn characteristics between the Pre (n=495) and Post groups (n=174). The Post group had significantly lower total MME (Post 110 MME [32, 325] versus Pre 230 [60, 840], p<0.001), MME/day (Post 33 MME/day [15, 54] versus Pre 52 [27, 80], p<0.001), and domain-specific total MME. No difference in average normalized pain scores was seen.Implementation of opioid-minimizing protocols for acute burn pain was associated with a significant reduction in inpatient opioid exposure without an increase in pain scores.
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Affiliation(s)
- Deepanjli Donthula
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Christopher R Conner
- the Department of Neurosurgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Van Thi Thanh Truong
- the Center for Clinical Research and Evidence-Based Medicine, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Charles Green
- the Center for Clinical Research and Evidence-Based Medicine, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Chuantao Jiang
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Michael W Wandling
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Spogmai Komak
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Todd F Huzar
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Sasha D Adams
- Center for Translational Injury Research, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Daniel J Freet
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - David J Wainwright
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Charles E Wade
- Center for Translational Injury Research, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Lillian S Kao
- Center for Translational Injury Research, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the Center for Clinical Research and Evidence-Based Medicine, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - John A Harvin
- Center for Translational Injury Research, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the Center for Clinical Research and Evidence-Based Medicine, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
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9
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Raman R, Fleming L. We Need to Talk About Codeine: an Implementation Study to reduce the number of Emergency Department patients discharged on high-strength co-codamol using the Behaviour Change Wheel. Emerg Med J 2021; 38:895-900. [PMID: 33658270 DOI: 10.1136/emermed-2020-209479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 02/08/2021] [Accepted: 02/13/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The crisis of prescription opioid addiction in the USA is well-documented. Though opioid consumption per capita is lower in the UK, prescribing has increased dramatically in recent decades with an associated increase in deaths from prescription opioid overdose. At one Scottish Emergency Department high rates of prescribing of take-home co-codamol (30/500 mg) were observed, including for conditions where opioids are not recommended by national guidelines. An Implementation Science approach was adopted to investigate this. METHODS A Behaviour Change Wheel analysis suggested several factors contributing to high opioid prescribing: poor awareness of codeine addiction risk, poor knowledge of NICE (National Institute for Health and Care Excellence) guidelines on common painful conditions, mistaken assumptions about patient expectations and ready access to a large stock of take-home co-codamol. Based on this analysis a combined Education/Persuasion intervention was implemented over a 1-month period (January 2019) reaching 93% of prescribers. An Environmental Restructuring intervention was introduced at 4 months, and co-codamol prescriptions were monitored over a 12-month follow-up period. Unplanned re-attendances and complaints related to analgesia were monitored as balancing measures. RESULTS The Education/Persuasion intervention was associated with a 59% reduction in co-codamol prescribing that was maintained over 12 months. The Environmental Restructuring intervention was not associated with any further reduction in prescribing. No increase in unplanned re-attendances occurred during the study period and no complaints were received relating to pain control. CONCLUSIONS The increasing incidence of prescription opioid addiction in the UK suggests the need for all clinicians who write opioid prescriptions to re-evaluate their practice. This study suggests that knowledge of addiction risk and prescribing guidelines is poor among Emergency Department prescribers. We show that a rapid and sustained reduction in prescribing of take-home opioids is feasible in a UK Emergency Department, and that this reduction was not associated with any increase in unplanned re-attendances or complaints related to analgesia.
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Affiliation(s)
- Rajendra Raman
- Accident and Emergency, Victoria Hospital, Kirkcaldy, UK
| | - Laura Fleming
- Accident and Emergency, Victoria Hospital, Kirkcaldy, UK
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10
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Sin B, Sikorska G, YauLin J, Bonitto RA, Motov SM. Comparing Nonopioids Versus Opioids for Acute Pain in the Emergency Department: A Literature Review. Am J Ther 2021; 28:e52-e86. [DOI: 10.1097/mjt.0000000000001098] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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11
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Wong A, Potter J, Brown NJ, Chu K, Hughes JA. Patient-Reported outcomes of pain care research in the adult emergency department: A scoping review. Australas Emerg Care 2020; 24:127-134. [PMID: 33187935 DOI: 10.1016/j.auec.2020.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/12/2020] [Accepted: 10/20/2020] [Indexed: 12/19/2022]
Abstract
Despite more than 30 years of research, pain in the emergency department (ED) setting is frequently undertreated. EDs prioritise process measures that often have tenuous links to patient-reported outcomes. However, process measures, such as time to the administration of first analgesic medication, are neither direct objective measures of analgesia nor appropriate surrogate markers of pain relief. Since pain is a subjective symptom that lacks an objective measure, pain research in any clinical environment, including EDs, should rely upon patient-reported outcomes. This scoping review examined patient-reported outcomes (PROs) and patient-reported outcome measures (PROMs) of pain care in the adult emergency department at the micro, meso and macro-level over the last ten years. We reviewed pain care research conducted on adults in EDs over the last ten years and identified 57 articles using 14 patient-reported outcomes of pain care falling into five broad areas, most without validation or adaption to the ED setting. Despite efforts made to incorporate PROs and PROMs into acute pain care research in the ED over the last ten years, there is still no gold-standard PROM in widespread use. We recommend the adaptation of existing tools with rigorous validation in ED populations.
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Affiliation(s)
- Alixandra Wong
- Faculty of Medicine, University of Queensland, St Lucia, Australia
| | - Joseph Potter
- Faculty of Medicine, University of Queensland, St Lucia, Australia; Logan Hospital, Meadowbrook, Australia
| | - Nathan J Brown
- Faculty of Medicine, University of Queensland, St Lucia, Australia; Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Kevin Chu
- Faculty of Medicine, University of Queensland, St Lucia, Australia; Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Australia
| | - James A Hughes
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Australia; School of Nursing, Queensland University of Technology, Kelvin Grove, Australia.
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12
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Yin X, Wang X, He C. Comparative efficacy of therapeutics for traumatic musculoskeletal pain in the emergency setting: A network meta-analysis. Am J Emerg Med 2020; 46:424-429. [PMID: 33131973 DOI: 10.1016/j.ajem.2020.10.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/05/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE Musculoskeletal pain control is essential in the management of trauma patients in the emergency department (ED). Here, we performed a network meta-analysis of the use of analgesics to manage traumatic musculoskeletal pain. METHOD This network meta-analysis (NMA) protocol was registered in PROSPERO (CRD42020150145). Electronic databases were searched for randomized controlled trials comparing systemic pharmaceutical interventions for treating traumatic musculoskeletal pain in the ED setting. The outcomes were global efficacy and changes in pain intensity. RESULTS Eighteen studies (2656 patients, four medication classes) met the inclusion criteria. The top-ranking medication class for global efficacy was nonsteroidal anti-inflammatory drugs (NSAIDs; network odds ratio: 0.52, 95% credible interval: 0.34-0.81, surface under the cumulative ranking curve score: 86). No interventions were more effective at decreasing pain intensity than opioids at 60 min. CONCLUSION NSAIDs were the most effective medications for treating traumatic musculoskeletal pain, and combination therapies may not have advantages in the ED setting.
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Affiliation(s)
- Xinbo Yin
- Faculty of Nursing, School of Medicine, Hunan Normal University, Changsha, Hunan, China; Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xiaokai Wang
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Caiyun He
- Faculty of Nursing, School of Medicine, Hunan Normal University, Changsha, Hunan, China.
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Scott G, Gong J, Kirkpatrick C, Jones P. Systematic review and meta-analysis of oral paracetamol versus combination oral analgesics for acute musculoskeletal injuries. Emerg Med Australas 2020; 33:107-113. [PMID: 32864884 DOI: 10.1111/1742-6723.13596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/05/2020] [Accepted: 07/08/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim of this systematic review and meta-analysis was to determine if a combination of analgesics conveys any significant clinical benefit over paracetamol alone in managing acute musculoskeletal injuries. METHODS Two reviewers independently searched MEDLINE (via PubMed), EMBASE and Cochrane electronic databases. Randomised controlled trials comparing paracetamol with paracetamol plus other oral analgesics in managing acute musculoskeletal injuries (e.g. sprains, contusions) were identified. Outcomes were reduction in pain score, adverse events and need for additional analgesia. Studies were critiqued using the Cochrane Risk of Bias Assessment Tool and data analysed using RevMAN meta-analysis software. RESULTS Six studies were included (n = 1254). No paediatric studies were identified. Five studies compared paracetamol to paracetamol plus NSAID. One study also included an opioid in the combination group. There was no clinically important difference between groups for reduction in pain score in the first 2 h, 24 h or 72 h. At 2 h the mean difference in reduction in pain score at rest on 100 mm VAS was 0.72 mm (-1.36, 2.79), P = 0.5. On activity it was -1.79 mm (-4.08, 0.49), P = 0.12. The risk of adverse events in ED was -0.00 (-0.04, 0.03). More patients receiving combination therapy required additional analgesia in the first 2 h: -0.03 (-0.06, -0.01), P = 0.01. CONCLUSION Paracetamol monotherapy is a reasonable first-line analgesic for acute musculoskeletal injuries as combining additional oral agents does not result in any significant additional analgesic effect.
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Affiliation(s)
- Gemma Scott
- Adult Emergency Department, Auckland City Hospital, Auckland, New Zealand
| | - Jiayi Gong
- Inpatient Pharmacy Department, Auckland City Hospital, Auckland, New Zealand
| | - Carl Kirkpatrick
- Centre for Medicine Use and Safety, Monash University, Melbourne, Victoria, Australia
| | - Peter Jones
- Adult Emergency Department, Auckland City Hospital, Auckland, New Zealand.,Department of Surgery, The University of Auckland, Auckland, New Zealand
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14
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Jones P, Lamdin R, Dalziel SR. Oral non-steroidal anti-inflammatory drugs versus other oral analgesic agents for acute soft tissue injury. Cochrane Database Syst Rev 2020; 8:CD007789. [PMID: 32797734 PMCID: PMC7438775 DOI: 10.1002/14651858.cd007789.pub3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Acute soft tissue injuries are common and costly. The best drug treatment for such injuries is not certain, although non-steroidal anti-inflammatory drugs (NSAIDs) are often recommended. There is concern about the use of oral opioids for acute pain leading to dependence. This is an update of a Cochrane Review published in 2015. OBJECTIVES To assess the benefits or harms of NSAIDs compared with other oral analgesics for treating acute soft tissue injuries. SEARCH METHODS We searched the CENTRAL, 2020 Issue 1, MEDLINE (from 1946), and Embase (from 1980) to January 2020; other databases were searched to February 2019. SELECTION CRITERIA We included randomised or quasi-randomised controlled trials involving people with acute soft tissue injury (sprain, strain, or contusion of a joint, ligament, tendon, or muscle occurring within 48 hours of inclusion in the study), and comparing oral NSAIDs versus paracetamol (acetaminophen), opioid, paracetamol plus opioid, or complementary and alternative medicine. The outcomes were pain, swelling, function, adverse effects, and early re-injury. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for eligibility, extracted data, and assessed risk of bias. We assessed the quality of the evidence using GRADE methodology. MAIN RESULTS We included 20 studies, with 3305 participants. Three studies included children only. The others included predominantly young adults; approximately 60% were male. Seven studies recruited people with ankle sprains only. Most studies were at low or unclear risk of bias; however, two were at high risk of selection bias, three were at high risk of bias from lack of blinding, and five were at high risk of selective outcome reporting bias. Some evidence relating to pain relief was high certainty. Other evidence was either moderate, low or very low certainty, reflecting study limitations, indirectness, imprecision, or combinations of these. Thus, we are certain or moderately certain about some of the estimates, and uncertain or very uncertain of others. Eleven studies, involving 1853 participants compared NSAIDs with paracetamol. There were no differences between the two groups in pain at one to two hours (1178 participants, 6 studies; high-certainty evidence), at days one to three (1232 participants, 6 studies; high-certainty evidence), and at day seven or later (467 participants, 4 studies; low-certainty evidence). There was little difference between the groups in numbers of participants with minimal swelling at day seven or later (77 participants, 1 study; low-certainty evidence). Very low-certainty evidence from three studies (386 participants) means we are uncertain of the finding of little difference between the two groups in return to function at day seven or later. There was low-certainty evidence from 10 studies (1504 participants) that NSAIDs may slightly increase the risk of gastrointestinal adverse events compared with paracetamol. There was low-certainty evidence from nine studies (1679 participants) of little difference in neurological adverse events between the NSAID and paracetamol groups. Six studies, involving 1212 participants compared NSAIDs with opioids. There was moderate-certainty evidence of no difference between the groups in pain at one hour (1058 participants, 4 studies), and low-certainty evidence for no difference in pain at days four or seven (706 participants, 1 study). There was very low-certainty evidence of no important difference between the groups in swelling (84 participants, 1 study). Participants in the NSAIDs group were more likely to return to function in 7 to 10 days (542 participants, 2 studies; low-certainty evidence). There was moderate-certainty evidence (1143 participants, 5 studies) that NSAIDs were less likely to result in gastrointestinal or neurological adverse events compared with opioids. Four studies, involving 240 participants, compared NSAIDs with the combination of paracetamol and an opioid. The applicability of findings from these studies is in question because the dextropropoxyphene combination analgesic agents used are no longer in general use. Very low-certainty evidence means we are uncertain of the findings of no differences between the two interventions in the numbers with little or no pain at day one (51 participants, 1 study), day three (149 participants, 2 studies), or day seven (138 participants, 2 studies); swelling (230 participants, 3 studies); return to function at day seven (89 participants, 1 study); and the risk of gastrointestinal or neurological adverse events (141 participants, 3 studies). No studies reported re-injury rates. No studies compared NSAIDs with oral complementary and alternative medicines, AUTHORS' CONCLUSIONS: Compared with paracetamol, NSAIDs make no difference to pain at one to two hours and at two to three days, and may make no difference at day seven or beyond. NSAIDs may result in a small increase in gastrointestinal adverse events and may make no difference in neurological adverse events compared with paracetamol. Compared with opioids, NSAIDs probably make no difference to pain at one hour, and may make no difference at days four or seven. NSAIDs probably result in fewer gastrointestinal and neurological adverse effects compared with opioids. The very low-certainly evidence for all outcomes for the NSAIDs versus paracetamol with opioid combination analgesics means we are uncertain of the findings of no differences in pain or adverse effects. The current evidence should not be extrapolated to adults older than 65 years, as this group was not well represented in the studies.
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Affiliation(s)
- Peter Jones
- Adult Emergency Department, Auckland City Hospital, Auckland, New Zealand
| | - Rain Lamdin
- Adult Emergency Department, Auckland City Hospital, Auckland, New Zealand
| | - Stuart R Dalziel
- Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
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15
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Montoy JCC, Coralic Z, Herring AA, Clattenburg EJ, Raven MC. Association of Default Electronic Medical Record Settings With Health Care Professional Patterns of Opioid Prescribing in Emergency Departments: A Randomized Quality Improvement Study. JAMA Intern Med 2020; 180:487-493. [PMID: 31961377 PMCID: PMC6990860 DOI: 10.1001/jamainternmed.2019.6544] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE Prescription opioids play a significant role in the ongoing opioid crisis. Guidelines and physician education have had mixed success in curbing opioid prescriptions, highlighting the need for other tools that can change prescriber behavior, including nudges based in behavioral economics. OBJECTIVE To determine whether and to what extent changes in the default settings in the electronic medical record (EMR) are associated with opioid prescriptions for patients discharged from emergency departments (EDs). DESIGN, SETTING, AND PARTICIPANTS This quality improvement study randomly altered, during a series of five 4-week blocks, the prepopulated dispense quantities of discharge prescriptions for commonly prescribed opioids at 2 large, urban EDs. These changes were made without announcement, and prescribers were not informed of the study itself. Participants included all health care professionals (physicians, nurse practitioners, and physician assistants) working clinically in either of the 2 EDs. Data were collected from November 28, 2016, through July 9, 2017, and analyzed from July 16, 2017, through May 14, 2018. INTERVENTIONS Default quantities for opioids were changed from status quo quantities of 12 and 20 tablets to null, 5, 10, and 15 tablets according to a block randomization scheme. Regardless of the default quantity, each health care professional decided for whom to prescribe opioids and could modify the quantity prescribed without restriction. MAIN OUTCOMES AND MEASURES The primary outcome was the number of tablets of opioid-containing medications prescribed under each default setting. RESULTS A total of 104 health care professionals wrote 4320 prescriptions for opioids during the study period. Using linear regression, an increase of 0.19 tablets prescribed (95% CI, 0.15-0.22) was found for each tablet increase in default quantity. When evaluating each of the 15 pairwise comparisons of default quantities (eg, 5 vs 15 tablets), a lower default was associated with a lower number of pills prescribed in more than half (8 of the 15) of the pairwise comparisons; there was a higher quantity in 1 and no difference in 6 comparisons. CONCLUSIONS AND RELEVANCE These findings suggest that default settings in the EMR may influence the quantity of opioids prescribed by health care professionals. This low-cost, easily implementable, EMR-based intervention could have far-reaching implications for opioid prescribing and could be used as a tool to help combat the opioid epidemic. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04155229.
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Affiliation(s)
| | - Zlatan Coralic
- Department of Emergency Medicine, University of California, San Francisco
| | - Andrew A Herring
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, California
| | - Eben J Clattenburg
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, California.,Tuba City Regional Health Care Corporation, Tuba City, Arizona
| | - Maria C Raven
- Department of Emergency Medicine, University of California, San Francisco
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16
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Godwin SA, Cherkas DS, Panagos PD, Shih RD, Byyny R, Wolf SJ. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache. Ann Emerg Med 2020; 74:e41-e74. [PMID: 31543134 DOI: 10.1016/j.annemergmed.2019.07.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This clinical policy from the American College of Emergency Physicians addressed key issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In the adult emergency department patient presenting with acute headache, are there risk-stratification strategies that reliably identify the need for emergent neuroimaging? (2) In the adult emergency department patient treated for acute primary headache, are nonopioids preferred to opioid medications? (3) In the adult emergency department patient presenting with acute headache, does a normal noncontrast head computed tomography scan performed within 6 hours of headache onset preclude the need for further diagnostic workup for subarachnoid hemorrhage? (4) In the adult emergency department patient who is still considered to be at risk for subarachnoid hemorrhage after a negative noncontrast head computed tomography, is computed tomography angiography of the head as effective as lumbar puncture to safely rule out subarachnoid hemorrhage? Evidence was graded and recommendations were made based on the strength of the available data.
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17
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Gong J, Colligan M, Kirkpatrick C, Jones P. Oral Paracetamol Versus Combination Oral Analgesics for Acute Musculoskeletal Injuries. Ann Emerg Med 2019; 74:521-529. [DOI: 10.1016/j.annemergmed.2019.05.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/15/2019] [Accepted: 05/21/2019] [Indexed: 11/28/2022]
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18
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Yan MJ, Wang T, Wu XM, Zhang W. Comparison of dexmedetomidine or sufentanil combined with ropivacaine for epidural analgesia after thoracotomy: a randomized controlled study. J Pain Res 2019; 12:2673-2678. [PMID: 31564959 PMCID: PMC6733349 DOI: 10.2147/jpr.s208014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 08/02/2019] [Indexed: 12/03/2022] Open
Abstract
Background Thoracotomy is frequently accompanied with moderate-to-severe postoperative pain, and excellent pain management is important for early rehabilitation. The purpose of this study is to investigate the effects of dexmedetomidine combined with ropivacaine for epidural analgesia after thoracotomy. Methods One hundred and thirty patients undergoing elective lung lobectomy were enrolled in the double-blind study and randomly divided into two groups. Group A received 0.5 µg/mL of dexmedetomidine plus 0.1% ropivacaine for postoperative analgesia, and group B (control group) received 0.5 µg/mL of sufentanil plus 0.1% ropivacaine for postoperative analgesia. Hemodynamic parameters were monitored. Pain intensity at rest was assessed using a visual analog scale (VAS) at 2, 4, 6,8, 12, 24, and 48 hrs postoperatively. Ramsay sedation score (RSS), analgesic consumption, postoperative respiratory depression, nausea and vomiting, pruritus, and bradycardia were recorded. Results The VAS values at rest during the postoperative 6–48 hrs were lower in group A than those in group B (P<0.05), and the RSS values were higher in group A during the postoperative 4–48 hrs compared to group B (P<0.05). Side effects were similar between the groups (P>0.05). Conclusion Dexmedetomidine combined with ropivacaine may provide better postoperative analgesia and sedative effect in patients undergoing thoracic surgery with fewer side effects. It is superior to sufentanil in analgesic effect during postoperative analgesia after thoracotomy.
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Affiliation(s)
- M J Yan
- Department of Anesthesiology, Chun'an First People's Hospital, Hangzhou 310000, People's Republic of China.,Department of Anesthesiology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou 310000, People's Republic of China
| | - T Wang
- Second Clinical College, Zhejiang Chinese Medical University, Hangzhou 310000, People's Republic of China
| | - X M Wu
- Department of Anesthesiology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou 310000, People's Republic of China
| | - W Zhang
- Department of Anesthesiology, Affiliated Women and Children's Hospital of Jiaxing University, Jiaxing 314000, People's Republic of China
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19
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Collinsworth KM, Goss DL. Battlefield Acupuncture and Physical Therapy Versus Physical Therapy Alone After Shoulder Surgery. Med Acupunct 2019; 31:228-238. [PMID: 31456869 DOI: 10.1089/acu.2019.1372] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective: Opioid pain medications are commonly prescribed postsurgically for pain. Few studies have investigated the effects of Battlefield Acupuncture (BFA) on postsurgical pain and pain-medication use. To date, no studies have investigated BFA's effectiveness for reducing postoperative shoulder pain and pain-medication use post surgery. The objective of this study was to determine if adding BFA to a rehabilitation protocol was effective for reducing pain and use of prescribed pain medications, compared to that protocol alone after shoulder surgery. Materials and Methods: Forty Department of Defense beneficiaries (ages 17-55) were randomized to either a standard-of-care group or a standard-of-care + BFA group prior to shoulder surgery. The standard BFA protocol was administered with semipermanent acupuncture needles emplaced on the subjects' ears for 3-5 days within 24 hours after shoulder surgery in an outpatient physical therapy setting. BFA was reapplied, as needed, up to 6 weeks postsurgically for pain management in the intervention group. The primary outcomes were visual analogue scale (VAS) pain rating and daily pain medication use by each subject. Secondary outcome measures were the Global Rating of Change and Patient Specific Functional scale. Outcome measures were obtained at 24 hours, 72 hours, 1 week, 2 weeks, and 6 weeks post surgery. Results: Significant differences in average and worst VAS pain change scores were noted between baseline and 7 days (P < 0.05). The main effect for time was significant (average and worst VAS pain) at all timepoints (P < 0.05), without time-group interactions seen. No significant differences between the groups in pain-medication use were observed (P > 0.05) Conclusions: BFA reduced postsurgical shoulder pain significantly between the groups' average and worst pain change scores between baseline and 7 days despite similar opioid and nonsteroidal anti-inflammatory drug use between the groups.
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Affiliation(s)
- Keith M Collinsworth
- Keller Army Community Hospital, West Point, NY.,Baylor-KACH Division 1 Sport Physical Therapy, Waco, TX
| | - Donald L Goss
- Keller Army Community Hospital, West Point, NY.,Baylor-KACH Division 1 Sport Physical Therapy, Waco, TX
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20
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Ridderikhof ML, Saanen J, Goddijn H, Van Dieren S, Van Etten-Jamaludin F, Lirk P, Goslings JC, Hollmann MW. Paracetamol versus other analgesia in adult patients with minor musculoskeletal injuries: a systematic review. Emerg Med J 2019; 36:493-500. [DOI: 10.1136/emermed-2019-208439] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 05/17/2019] [Accepted: 05/20/2019] [Indexed: 12/26/2022]
Abstract
ObjectivesPain treatment in acute musculoskeletal injuries usually consists of paracetamol, non-steroidal antiinflammatory drugs (NSAIDs) or opioids. It would be beneficial to determine whether paracetamol is as effective as other analgesics. The objective of this study was to evaluate available evidence regarding efficacy of paracetamol in these patients.MethodsEmbase, MEDLINE, Cochrane and relevant trial registers were searched from inception to 14 February 2018 by two independent reviewers to detect all randomised studies with adult patients with acute minor musculoskeletal injuries treated with paracetamol as compared with other analgesics. There were no language or date restrictions. Two independent reviewers evaluated risk of bias and quality of evidence. Primary outcome was decrease in pain scores during the first 24 hours, and secondary outcomes included pain decrease beyond 24 hours, need for additional analgesia and occurrence of adverse events.ResultsSeven trials were included, evaluating 2100 patients who were treated with paracetamol or NSAIDs or the combination of both as comparisons, of which only four studies addressed the primary outcome. No studies were found comparing paracetamol with opioids. There were no differences in analgesic effectiveness within and beyond 24 hours, nor in need for additional analgesia and occurrence of adverse events. Overall, quality of evidence was low. Because of methodological inconsistencies, a meta-analysis was not possible.ConclusionsBased on available evidence, paracetamol is as effective as NSAIDs or the combination of both in treating pain in adult patients with minor musculoskeletal injuries in the acute setting. The quality of evidence is low.
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21
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Welch S. Pharmacy research in the emergency medicine environment. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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22
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Aitken P, Stanescu I, Playne R, Zhang J, Frampton CMA, Atkinson HC. An integrated safety analysis of combined acetaminophen and ibuprofen (Maxigesic ® /Combogesic ®) in adults. J Pain Res 2019; 12:621-634. [PMID: 30804681 PMCID: PMC6371943 DOI: 10.2147/jpr.s189605] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Acetaminophen (APAP) and ibuprofen (IBP) are two analgesic compounds with a long history of use. Both are considered safe at recommended over-the-counter daily doses. Chronic use, high doses, or concomitant medication can produce safety risks for both drugs. APAP is associated with increased risk of hepatic injury, while IBP can produce gastric bleeding and thromboembolic events. Using a combination of APAP and IBP provides superior analgesia without transgressing daily dose limits of each individual drug. METHODS The present study aimed to determine if treatment with a fixed-dose combination (FDC) containing APAP and IBP results in any unexpected adverse events (AEs) and/or changes in the safety profiles of its two ingredients compared to monotherapy. The analysis will examine clinical safety data obtained from either single dose trials, multiple dose trials, a long-term exposure trial, and post-marketing surveillance data of APAP/IBP FDC tablets (Maxigesic®/Combogesic®, AFT Pharmaceuticals Ltd). The largest dataset was obtained by pooling the four randomized-controlled, multiple-dose clinical studies with either APAP 325 mg + IBP 97.5 mg (FDC 325/97.5, three tablets per dose) or APAP 500 mg + IBP 150 mg (FDC 500/150, two tablets per dose). At maximum doses, the two FDCs are bioequivalent, permitting the pooling of data for the analysis of safety. RESULTS A safety population of 922 patients who received full doses of either FDC, APAP alone, IBP alone, or placebo was compiled from the four studies. A total of 521 AEs were experienced with the incidence of FDC AEs similar to or below either monotherapy group or placebo. The FDC did not alter the incidence and percentage of the most common AEs, including gastrointestinal events and postoperative bleeding. CONCLUSION Overall, the FDC is well tolerated and has a strong safety profile at single and multiple doses with improved efficacy over monotherapy.
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Affiliation(s)
- Phillip Aitken
- Drug Development, AFT Pharmaceuticals Ltd, Auckland, New Zealand,
| | - Ioana Stanescu
- Drug Development, AFT Pharmaceuticals Ltd, Auckland, New Zealand,
| | - Rebecca Playne
- Drug Development, AFT Pharmaceuticals Ltd, Auckland, New Zealand,
| | - Jennifer Zhang
- Drug Development, AFT Pharmaceuticals Ltd, Auckland, New Zealand,
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Pan Z, Qi Y, Wen Y, Chen L. Intravenous morphine titration vs. oral hydrocodone/acetaminophen for adults with lower extremity displaced fracture in an emergency department setting: A randomized controlled trial. Exp Ther Med 2018; 16:3674-3679. [PMID: 30233725 DOI: 10.3892/etm.2018.6606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 06/25/2018] [Indexed: 12/23/2022] Open
Abstract
The objective of the present study was to test the hypothesis that intravenous morphine titration provides superior analgesia to oral hydrocodone/acetaminophen for patients with lower extremity displaced fracture in an emergency department (ED) setting. A prospective, randomized clinical trial of ED patients suffering acute lower extremity displaced fracture pain was performed with a total of 206 participants included. After application of exclusion criteria, the cohort comprised 166 patients, 85 of which were randomly allocated to the oral hydrocodone/acetaminophen (5 mg/500 mg) group and 81 to the intravenous morphine titration (every 5 min by 3-mg increments) group. The main outcome was the visual analogue scale (VAS) at different time-points after the first dose of analgesic was administered. Secondary outcomes included the VAS change during the skeletal traction operation and short-term adverse events. The results demonstrated that the initial VSA of the participants was similar at the baseline on arrival at the ED (P=0.2582). At the time-points of 5, 15, 30 min after the first dose of analgesic administered, the intravenous morphine titration group exhibited a greater VAS reduction compared with that in the oral hydrocodone/acetaminophen group (P<0.01). The differences between the 2 groups were not statistically significant at 1 h or thereafter. The incidence of short-term adverse events was similar between the 2 groups but sedation, whose incidence in the morphine group was markedly increased, may not be arbitrarily attributed to adverse events. It was concluded that, compared with oral hydrocodone/acetaminophen, intravenous morphine titration provided a rapid and sufficient pain relief and equivalent short-term adverse events for patients with lower extremity displaced fracture in an ED setting.
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Affiliation(s)
- Zhengqi Pan
- Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Yongjian Qi
- Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Yinxian Wen
- Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Liaobin Chen
- Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
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Herzig SJ, Mosher HJ, Calcaterra SL, Nuckols TK. Reply to "In Reference to 'Improving the Safety of Opioid Use for Acute Noncancer Pain in Hospitalized Adults: A Consensus Statement from the Society of Hospital Medicine'". J Hosp Med 2018; 13:728. [PMID: 30261091 PMCID: PMC7556321 DOI: 10.12788/jhm.3058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Shoshana J Herzig
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
- Harvard Medical School, Boston, Massachusetts, USA
| | - Hilary J Mosher
- The Comprehensive Access and Delivery Research and Evaluation Center at the Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa, USA
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Susan L Calcaterra
- Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA
- Department of Medicine, Division of General Internal Medicine, University of Colorado, Aurora, Colorado, USA
| | - Teryl K Nuckols
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
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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; 318:1661-1667. [PMID: 29114833 PMCID: PMC5818795 DOI: 10.1001/jama.2017.16190] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE The choice of analgesic to treat acute pain in the emergency department (ED) lacks a clear evidence base. The combination of ibuprofen and acetaminophen (paracetamol) may represent a viable nonopioid alternative. OBJECTIVES To compare the efficacy of 4 oral analgesics. DESIGN, SETTINGS, AND PARTICIPANTS Randomized clinical trial conducted at 2 urban EDs in the Bronx, New York, that included 416 patients aged 21 to 64 years with moderate to severe acute extremity pain enrolled from July 2015 to August 2016. INTERVENTIONS Participants (104 per each combination analgesic group) received 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; or 30 mg of codeine and 300 mg of acetaminophen. MAIN OUTCOMES AND MEASURES The primary outcome was the between-group difference in decline in pain 2 hours after ingestion. Pain intensity was assessed using an 11-point numerical rating scale (NRS), in which 0 indicates no pain and 10 indicates the worst possible pain. The predefined minimum clinically important difference was 1.3 on the NRS. Analysis of variance was used to test the overall between-group difference at P = .05 and 99.2% CIs adjusted for multiple pairwise comparisons. RESULTS Of 416 patients randomized, 411 were analyzed (mean [SD] age, 37 [12] years; 199 [48%] women; 247 [60%] Latino). The baseline mean NRS pain score was 8.7 (SD, 1.3). At 2 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 largest difference in decline in the NRS pain score from baseline to 2 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. Adverse events were not assessed. CONCLUSIONS AND RELEVANCE 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. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02455518.
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Affiliation(s)
- Andrew K. Chang
- Department of Emergency Medicine, Albany Medical College, Albany, New York
| | - Polly E. Bijur
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - David Esses
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Douglas P. Barnaby
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Jesse Baer
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
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