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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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Jenkin DE, Naylor JM, Descallar J, Harris IA. Effectiveness of Oxycodone Hydrochloride (Strong Opioid) vs Combination Acetaminophen and Codeine (Mild Opioid) for Subacute Pain After Fractures Managed Surgically: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2134988. [PMID: 34787656 PMCID: PMC8600392 DOI: 10.1001/jamanetworkopen.2021.34988] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Patients with a surgically managed fracture are commonly discharged from the hospital with a strong opioid prescription, but limited evidence exists to support this practice. OBJECTIVE To test the hypothesis that strong opioids provide greater analgesia than mild opioids over the first week postdischarge from hospital after fracture surgical treatment. DESIGN, SETTING, AND PARTICIPANTS This double-blind, superiority, randomized clinical trial was conducted at a single-center, major trauma hospital in Sydney, Australia. Participants were inpatients who had sustained an acute nonpathological facture of a long bone or the pelvis, patella, calcaneus, or talus who were treated with surgical fixation and enrolled from July 27, 2016, to August 22, 2017. Data were analyzed from June through October 2018. INTERVENTIONS Initiation at discharge of oxycodone hydrochloride 5 mg of 10 mg (ie, 1 or 2 tablets) or combination acetaminophen and codeine 500 mg and 8 mg or 1000 mg and 16 mg (ie, 1 or 2 tablets) 4 times daily for a maximum duration of 3 weeks. MAIN OUTCOMES AND MEASURES The primary outcome was the mean of daily pain scores collected during week 1 of treatment measured using the Numerical Pain Rating Scale (NRS). Participants were asked to rate their mean pain over the previous 24 hours daily using an NRS score from 0 to 10, with 0 representing no pain and 10 representing the worst pain imaginable. The key secondary outcomes were EuroQol 5-Dimension 5-Level Questionnaire (EQ-5D-5L) responses, worst pain, medication adverse events, global perceived effect, and return to work. RESULTS A total of 120 patients with 1 or more acute orthopedic fractures requiring surgical fixation were randomized, including 59 patients in the strong-opioid group (43 [72.9%] men; mean [SD] age, 36.0 [14.1] years; mean oral morphine equivalent for days 1-7 of 32.9 mg) and 61 patients in the mild opioid group (47 [77.1%] men; mean [SD] age, 38.2 [13.5] years; mean oral morphine equivalent for days 1-7 of 5.5 mg). From days 1 to 7 postdischarge, the mean daily NRS mean pain score was 4.04 (95% Cl, 3.67 to 4.41) in the strong opioid group and 4.54 (95% Cl, 4.17 to 4.90) in the mild opioid group. The between-group difference of the primary outcome was not statistically significant (-0.50 [95% Cl, -1.11 to 0.12]; P = .11) despite a 6-fold increased dose of opioids being delivered in the strong opioid group. CONCLUSIONS AND RELEVANCE This study found that treatment with strong opioid medication subacutely was not superior to treatment with milder medication for treatment of pain among patients with surgically managed orthopedic fractures. These findings suggest that ongoing first-line strong opioid use after discharge from the hospital should not be supported. TRIAL REGISTRATION Australia New Zealand Clinical Trial Registry No.: ACTRN12616000941460.
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Affiliation(s)
- Deanne E. Jenkin
- University of New South Wales, South Western Sydney Clinical School, Sydney, Australia
- Whitlam Orthopaedic Research Centre, Liverpool, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- Presently with Daffodil Centre, University of Sydney, a joint venture with Cancer Council New South Wales, Kings Cross, New South Wales, Australia
| | - Justine M. Naylor
- University of New South Wales, South Western Sydney Clinical School, Sydney, Australia
- Whitlam Orthopaedic Research Centre, Liverpool, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- Liverpool Hospital, South Western Sydney Local Health District, Sydney, New South Wales, Australia
| | - Joseph Descallar
- University of New South Wales, South Western Sydney Clinical School, Sydney, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Ian A. Harris
- University of New South Wales, South Western Sydney Clinical School, Sydney, Australia
- Whitlam Orthopaedic Research Centre, Liverpool, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- Liverpool Hospital, South Western Sydney Local Health District, Sydney, New South Wales, Australia
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Bijur PE, Friedman BW, Irizarry E, Chang AK, Gallagher EJ. A Randomized Trial Comparing the Efficacy of Five Oral Analgesics for Treatment of Acute Musculoskeletal Extremity Pain in the Emergency Department. Ann Emerg Med 2020; 77:345-356. [PMID: 33358232 DOI: 10.1016/j.annemergmed.2020.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 10/01/2020] [Accepted: 10/05/2020] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE We compare the efficacy and adverse effects of 5 oral analgesics in emergency department (ED) patients aged 21 to 64 years with acute musculoskeletal pain. METHODS This was a randomized clinical trial conducted in 2 urban EDs. Patients received 400 mg ibuprofen/1,000 mg acetaminophen, 800 mg ibuprofen/1,000 mg acetaminophen, 30 mg codeine/300 mg acetaminophen, 5 mg hydrocodone/300 mg acetaminophen, or 5 mg oxycodone/325 mg acetaminophen. The primary outcome was change in pain before administration of medication (baseline) to 1 hour postbaseline. A numeric rating scale was used, varying from 0="no pain" to 10="worst imaginable pain." Secondary outcomes included receipt of rescue medication and adverse effects at 1 and 2 hours postbaseline. ANOVA was used to test differences in the primary outcome between treatment groups. RESULTS Six hundred participants, predominantly men and Latino, were enrolled. Change in pain from baseline to 60 minutes did not differ by treatment (P=.69). The mean change in pain in numeric rating scale units was 400 mg ibuprofen/1,000 mg acetaminophen 3.0 (95% confidence interval [CI] 2.6 to 3.5); 800 mg ibuprofen/1,000 mg acetaminophen 3.0 (95% CI 2.5 to 3.5), 30 mg codeine/300 mg acetaminophen 3.4 (95% CI 2.9 to 3.9), 5 mg hydrocodone/300 mg acetaminophen 3.1 (95% CI 2.7 to 3.5), and 5 mg oxycodone/325 mg acetaminophen 3.3 (95% CI 2.8 to 3.7). Rescue medication was received before 1 hour had elapsed by 2 patients receiving 400 mg ibuprofen/1,000 mg acetaminophen (1.7%), 3 patients receiving 800 mg ibuprofen/1,000 mg acetaminophen (2.5%), zero patients receiving 30 mg codeine/300 mg acetaminophen (0.0%), 3 patients receiving 5 mg hydrocodone/300 mg acetaminophen (2.5%), and zero patients receiving 5 mg oxycodone/325 mg acetaminophen (0.0%) (P=.21). More patients who received opioids were nauseated or vomited compared with those who did not: 6.7% versus 1.7% (5.0% difference; 95% CI 1.7% to 8.2%). The findings at 2 hours were similar. CONCLUSION No analgesic was more efficacious than others 1 or 2 hours after baseline. There was significantly more nausea and vomiting among patients treated with opioids.
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Affiliation(s)
- Polly E Bijur
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY.
| | - Benjamin W Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Eddie Irizarry
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Andrew K Chang
- Department of Emergency Medicine, Albany Medical Center, Albany, NY
| | - E John Gallagher
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY
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Daoust R, Paquet J, Cournoyer A, Piette É, Morris J, Lessard J, Lavigne G, Chauny JM. Relationship between acute pain trajectories after an emergency department visit and chronic pain: a Canadian prospective cohort study. BMJ Open 2020; 10:e040390. [PMID: 33293313 PMCID: PMC7722811 DOI: 10.1136/bmjopen-2020-040390] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Inadequate acute pain management can reduce the quality of life, cause unnecessary suffering and can often lead to the development of chronic pain. Using group-based trajectory modelling, we previously identified six distinct pain intensity trajectories for the first 14-day postemergency department (ED) discharge; two linear ones with moderate or severe pain during follow-up (~40% of the patients) and four cubic polynomial order trajectories with mild or no pain at the end of the 14 days (low final pain trajectories). We assessed if previously described acute pain intensity trajectories over 14 days after ED discharge are predictive of chronic pain 3 months later. DESIGN Prospective cohort study. SETTING Tertiary care trauma centre academic hospital. PARTICIPANTS This study included 18 years and older ED patients who consulted for acute (≤2 weeks) pain conditions that were discharged with an opioid prescription. Patients completed a 14-day diary in which they listed their daily pain intensity (0-10 numeric rating scale). OUTCOMES Three months after ED visit, participants were questioned by phone about their current pain intensity (0-10 numeric rating scale). Chronic pain was defined as patients with current pain intensity ≥4 at 3 months. RESULTS A total of 305 participants remained in the study at 3 months, 49% were women and a mean age of 55±15 years. Twelve per cent (11.9; 95% CI 8.2 to 15.4) of patients had chronic pain at the 3-month follow-up. Controlling for age, sex and pain condition, patients with moderate or severe pain trajectories and those with only a severe pain trajectory were respectively 5.1 (95% CI 2.2 to 11.8) and 8.2 (95% CI 3.4 to 20.0) times more likely to develop chronic pain 3 months later compared with patients in the low final pain trajectories. CONCLUSION Specific acute pain trajectories following an ED visit are closely related to the development of chronic pain 3 months later. TRIAL REGISTRATION NUMBER NCT02799004; Results.
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Affiliation(s)
- Raoul Daoust
- Emergency, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
- Faculte de medecine, Université de Montréal, Montréal, Quebec, Canada
| | - Jean Paquet
- Emergency, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
| | - Alexis Cournoyer
- Faculte de medecine, Université de Montréal, Montréal, Quebec, Canada
- Department of Emergency Medicine, Hopital du Sacre-Coeur de Montreal, Montréal, Quebec, Canada
| | - Éric Piette
- Faculte de medecine, Université de Montréal, Montréal, Quebec, Canada
| | - Judy Morris
- Department of Emergency Medicine, Hopital du Sacre-Coeur de Montreal, Montréal, Quebec, Canada
| | - Justine Lessard
- Emergency, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
- Faculte de medecine, Université de Montréal, Montréal, Quebec, Canada
| | - Gilles Lavigne
- Médecine Dentaire, Université de Montréal, Montreal, Quebec, Canada
| | - Jean-Marc Chauny
- Department of Emergency Medicine, Hopital du Sacre-Coeur de Montreal, Montréal, Quebec, Canada
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Chang AK, Bijur PE, Ata A, Campbell C, Pearlman S, White D, Chertoff A, Restivo A, Gallagher EJ. Randomized Clinical Trial of Intravenous Acetaminophen as an Analgesic Adjunct for Older Adults With Acute Severe Pain. Acad Emerg Med 2019; 26:402-409. [PMID: 30118582 DOI: 10.1111/acem.13556] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/06/2018] [Accepted: 08/13/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Older adults are at risk for undertreatment of pain. We examined intravenous (IV) acetaminophen as an analgesic adjunct to IV opioids in the care of older emergency department (ED) patients with acute severe pain. METHODS This was a randomized clinical trial conducted in two EDs in the Bronx, New York. Eligible adults aged 65 years and older with acute severe pain were randomized to 0.5 mg of IV hydromorphone and 1 g of IV acetaminophen or 0.5 mg of IV hydromorphone and 100 mL of normal saline placebo. The primary outcome was the between group difference in improvement of numerical rating scale (NRS) pain scores at 60 minutes. Secondary outcomes were the between-group differences in the proportion of patients who chose to forgo additional pain medications at 60 minutes; the proportion who developed side effects; the proportion who required rescue analgesia; and between-group differences in NRS pain scores at 5, 15, 30, and 45 minutes. RESULTS Eighty-one patients were allocated to each arm. Eighty patients in the IV acetaminophen arm and 79 patients in the placebo arm had sufficient data for analysis. At 60 minutes, patients in the hydromorphone + IV acetaminophen group improved by 5.7 NRS units while those in the hydromorphone + placebo group improved by 5.2 NRS units, for a difference of 0.6 NRS units (95% confidence interval [CI] = -0.4 to 1.5). A total of 28.7% of patients in the hydromorphone + IV acetaminophen group wanted more analgesia at 60 minutes versus 29.1% in the hydromorphone + placebo group, for a difference of -0.4% (95% CI = -14.3% to 13.5%). These differences were neither clinically nor statistically significant. Safety profiles were similar in both groups. CONCLUSION In this randomized clinical trial, the addition of IV acetaminophen to IV hydromorphone as an adjunctive analgesic for acute, severe, pain in older adults provided neither clinically nor statistically superior pain relief when compared to hydromorphone alone within the first hour of treatment.
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Affiliation(s)
- Andrew K. Chang
- Department of Emergency Medicine Albany Medical College AlbanyNY
| | - Polly E. Bijur
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
| | - Ashar Ata
- Department of Emergency Medicine Albany Medical College AlbanyNY
| | - Caron Campbell
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
| | - Scott Pearlman
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
| | - Deborah White
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
| | - Andrew Chertoff
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
| | - Andrew Restivo
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
| | - E. John Gallagher
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
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Gammal RS, Caudle KE, Quinn CT, Wang WC, Gaedigk A, Prows CA, Haidar CE, Taylor AK, Klein TE, Sangkuhl K, Hankins JS, Crews KR. The Case for Pharmacogenetics-Guided Prescribing of Codeine in Children. Clin Pharmacol Ther 2018; 105:1300-1302. [PMID: 30467830 DOI: 10.1002/cpt.1260] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 10/12/2018] [Indexed: 11/07/2022]
Affiliation(s)
- Roseann S Gammal
- Pharmacy Practice, MCPHS University School of Pharmacy, Boston, Massachusetts, USA.,Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Kelly E Caudle
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Charles T Quinn
- Pediatric Sickle Cell Program, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Winfred C Wang
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Andrea Gaedigk
- Pharmacogenetics Core Laboratory, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Cynthia A Prows
- Divisions of Human Genetics and Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Cyrine E Haidar
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Annette K Taylor
- Molecular Genetics, Colorado Coagulation, Laboratory Corporation of America Holdings, Englewood, Colorado, USA
| | - Teri E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Katrin Sangkuhl
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Jane S Hankins
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Kristine R Crews
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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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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Nadeau R, Hasstedt K, Sunstrum AB, Wagner C, Tu H. Addressing the Opioid Epidemic: Impact of Opioid Prescribing Protocol at the University of Minnesota School of Dentistry. Craniomaxillofac Trauma Reconstr 2018; 11:104-110. [PMID: 29892324 DOI: 10.1055/s-0038-1649498] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 03/17/2018] [Indexed: 10/16/2022] Open
Abstract
Prescription opioid medications continue to be abused on an epidemic level and have been shown to be a "gateway" drug to heroin abuse. Individuals experimenting with opioids commonly fall in the 10- to 19-year age range in which dentists are the highest prescribers. To reduce the number of excess opioids, the Department of Oral and Maxillofacial Surgery, University of Minnesota, developed and implemented an evidence-based opioid prescribing policy. Data were collected via electronic health record for the previous year and compared with the year following the protocol implementation. The results showed a drastic decrease (>46%) in the number of prescriptions given over a 1-year period. All departments reported a decrease in opioid prescriptions and the average number of tablets per prescription. The concern of undertreating pain was not found to be significant, as there was no increase in after-hours calls, recall appointments, or documentable emergency room visits. The results support the efficacy of an opioid prescribing policy's ability to lower the frequency and number of opioids given to patients, while still adequately treating patients' pain. Continued evaluation and modifications of the protocol and close monitoring of prescriber habits will enhance patients' pain control while also limiting the number of opioids available for abuse.
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Affiliation(s)
- Robert Nadeau
- Department of Oral and Maxillofacial Surgery, University of Minnesota School of Dentistry, Minneapolis, Minnesota
| | - Kristopher Hasstedt
- Department of Oral and Maxillofacial Surgery, University of Minnesota School of Dentistry, Minneapolis, Minnesota
| | - Ashley Brooke Sunstrum
- Department of Oral and Maxillofacial Surgery, University of Minnesota School of Dentistry, Minneapolis, Minnesota
| | - Chad Wagner
- Department of Oral and Maxillofacial Surgery, University of Minnesota School of Dentistry, Minneapolis, Minnesota
| | - Harold Tu
- Department of Oral and Maxillofacial Surgery, University of Minnesota School of Dentistry, Minneapolis, Minnesota
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Le Cornec C, Lariby S, Brenckmann V, Hardouin JB, Ecoffey C, Le Pottier M, Fradin P, Broch H, Kabbaj A, Auffret Y, Deciron F, Longo C, Javaudin F, Le Bastard Q, Jenvrin J, Montassier E. Is intravenously administered, subdissociative-dose KETAmine non-inferior to MORPHine for prehospital analgesia (the KETAMORPH study): study protocol for a randomized controlled trial. Trials 2018; 19:260. [PMID: 29716637 PMCID: PMC5930801 DOI: 10.1186/s13063-018-2634-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 04/10/2018] [Indexed: 04/18/2023] Open
Abstract
Background Acute pain is a common condition among prehospital patients and prompt management is pivotal. Opioids are the most frequently analgesics used in the prehospital setting. However, opioids are highly addictive, and some patients may develop opioid dependence, even when they are exposed to brief opioid treatments. Therefore, alternative non-opioid analgesia should be developed to manage pain in the prehospital setting. Used at subdissociative doses, ketamine, a noncompetitive N-methyl-D-aspartate and glutamate receptor antagonist, provides analgesic effects accompanied by preservation of protective airway reflexes. In this context, we will carry out a randomized controlled, open-label, multicenter trial to compare a subdissociative dose of ketamine to morphine to provide pain relief in the prehospital setting, in patients with traumatic and non-traumatic pain. Methods/design This will be a multicenter, single-blind, randomized controlled trial. Consecutive adults will be enrolled in the prehospital setting if they experience moderate to severe, acute, non-traumatic and traumatic pain, defined as a numeric rating scale score greater or equal to 5. Patients will be randomized to receive ketamine or morphine by intravenous push. The primary outcome will be the between-group difference in mean change in numeric rating scale pain scores measured from the time before administration of the study medication to 30 min later. Discussion This upcoming randomized clinical trial was design to assess the efficacy and safety of ketamine, an alternative non-opiate analgesia, to manage non-traumatic and traumatic pain in the prehospital setting. We aim to provide evidence to change prescribing practices to reduce exposition to opioids and the subsequent risk of addiction. Trial registration ClinicalTrials.gov, ID: NCT03236805. Registered on 2 August 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2634-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Clément Le Cornec
- Emergency Department, Nantes University Hospital, 44000, Nantes, France
| | - Said Lariby
- Tours University Hospital, Emergency Medicine Department, Tours, France
| | - Vivien Brenckmann
- Emergency Department and Mobile Intensive Care Unit, CHU Grenoble Alpes, 38043, Grenoble Cedex 09, France
| | - Jean Benoit Hardouin
- SPHERE U1246, Inserm, université de Nantes-université de Tours, 44000, Nantes, France
| | - Claude Ecoffey
- Department of Anaesthesia-Emergencies-Intensive Care and Internal Medicine and Geriatrics, Hôpital Pontchaillou, Université de Rennes 1, 2 Rue Henri Le Guilloux, 35033, Rennes Cedex, France
| | - Marion Le Pottier
- Emergency Department, Centre Hospitalier Universitaire Angers, Angers, France
| | - Philippe Fradin
- Emergency Department, La Roche sur Yon Hospital, La Roche Sur Yon, France
| | - Hélène Broch
- Emergency Department, Châteaubriant Hospital, Châteaubriant, France
| | - Amine Kabbaj
- Emergency Department, Saint Nazaire Hospital, Saint Nazaire, France
| | - Yannick Auffret
- Quimper Hospital CHIC, Emergency Department SAMU, 29000, Quimper, France
| | | | - Céline Longo
- Emergency Department, Nantes University Hospital, 44000, Nantes, France
| | - François Javaudin
- Emergency Department, Nantes University Hospital, 44000, Nantes, France
| | | | - Joël Jenvrin
- Emergency Department, Nantes University Hospital, 44000, Nantes, France
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Serinken M, Eken C, Karcıoğlu Ö. Intravenous Dexketoprofen versus Intravenous Paracetamol for Dysmenorrhea: A Randomized Controlled Trial. Balkan Med J 2018. [PMID: 29526831 PMCID: PMC6060974 DOI: 10.4274/balkanmedj.2016.0536] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Dysmenorrhea is one of the most common acute pain disorders among women of reproductive age. AIMS To compare the effects of IV paracetamol with dexketoprofen in patients presenting with primary dysmenorrhea to the emergency department. STUDY DESIGN Randomized controlled trial. METHODS Patients over 18 years old presenting with pelvic pain related to menstruation were eligible for the study. Study patients received 1 g paracetamol or 50 mg dexketoprofen in 100 mL normal saline with a 4-5 minute infusion via the intravenous route. Pain intensity was measured by a visual analog scale at 15 and 30 minutes. Patients were randomized and assigned to either of two study arms via sealed envelopes. Study drugs were identical in color, and thus both personnel and patients were blinded to the study drug. The dexketoprofen group comprised 49 patients, and the paracetamol group had 50 patients in the final analysis. RESULTS The mean age of the study subjects was 20.9±2.5 and the mean duration of the pain was 1.9±1.7 (median: 1, interquartile range: 1 to 2) hours. Both dexketoprofen (median change: 33, 95% CI: 24 to 38) and paracetamol (median change: 21, 95% CI: 12 to 32) effectively reduced the pain at 15 minutes, which was repeated at 30 minutes (median change: 63, 95% CI: 57 to 65 vs 55.5, 95% CI: 50 to 59, respectively). Pain improvement in the dexketoprofen group was better than in the paracetamol group at 15 (median difference: 8, 95% CI: 0 to 16, p=0.048) and 30 (median difference: 6, 95% CI: 1 to 12, p=0.028) minutes, which was statistically significant but not clinically significant. CONCLUSION Dexketotoprofen has a better visual analogue scale score that is not clinically relevant compared to paracetamol.
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Affiliation(s)
- Mustafa Serinken
- Department of Emergency Medicine, Pamukkale University School of Medicine, Denizli, Turkey
| | - Cenker Eken
- Department of Emergency Medicine, Akdeniz University School of Medicine, Antalya, Turkey
| | - Özgür Karcıoğlu
- Clinic of Emergency Medicine, İstanbul Training and Research Hospital, İstanbul, Turkey
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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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12
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Graudins A, Meek R, Parkinson J, Egerton-Warburton D, Meyer A. A randomised controlled trial of paracetamol and ibuprofen with or without codeine or oxycodone as initial analgesia for adults with moderate pain from limb injury. Emerg Med Australas 2016; 28:666-672. [PMID: 27599896 DOI: 10.1111/1742-6723.12672] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 06/13/2016] [Accepted: 07/18/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Compare pain relief from non-opioid, codeine and oxycodone analgesic regimens in adults with moderate pain from limb injury. METHOD Double-blind, randomised, controlled, non-inferiority trial. Three regimens of six tablets, each included 2 × 500 mg paracetamol and 2 × 200 mg ibuprofen with 2 × 100 mg thiamine (non-opioid), 2 × 30 mg codeine (codeine) or 2 × 5 mg oxycodone tablets (oxycodone). PRIMARY OUTCOME difference in mean visual analogue scale (VAS) change between groups at 30 min, with a limit of inferiority of 13. Secondary outcomes included mean change in VAS rating from baseline to 30 min for each group, patient satisfaction, need for additional analgesia and adverse events. Pain ratings taken at 60 and 90 min for patients still in ED are described. RESULTS Of 182 patients randomised, non-opioid, codeine and oxycodone numbers were 61, 62 and 59. Differences (95% CI) between groups at 30 min were as follows: non-opioid versus codeine -2.6 (-8.8 to 3.6); non-opioid versus oxycodone -2.7 (-9.3 to 3.9); codeine versus oxycodone 0.1 (-6.6 to 6.4). Mean VAS reductions for non-opioid, codeine and oxycodone were -13.5, -16.1 and -16.2 mm, respectively. Satisfaction with analgesia was reported by 77.6% (64.7-87.5), 81.0% (67.2-89.0) and 73.6% (59.7-84.7) and adverse events by 3.3% (0.4-11.3), 1.6% (0.4-8.7) and 16.9% (8.4-29.0), respectively. Mean VAS reductions at 60 and 90 min were as follows: -23.2 and -18.7 mm for non-opioid; -30.7 and -33.3 mm for codeine; and -26.1 and -31.7 mm for oxycodone. CONCLUSION At 30 min, analgesic effects of non-opioid, codeine and oxycodone groups were non-inferior.
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Affiliation(s)
- Andis Graudins
- Monash Health Emergency Medicine Research Unit, Dandenong Hospital, Melbourne, Victoria, Australia.,Monash Emergency, Dandenong Hospital, Melbourne, Victoria, Australia.,School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Robert Meek
- Monash Emergency, Dandenong Hospital, Melbourne, Victoria, Australia.,School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Jacqueline Parkinson
- Pharmacy Department, Monash Medical Center, Melbourne, Victoria, Australia.,School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Diana Egerton-Warburton
- Monash Emergency, Monash Medical Center, Melbourne, Victoria, Australia.,School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Alastair Meyer
- Monash Emergency, Casey Hospital, Melbourne, Victoria, Australia.,School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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Gammal RS, Crews KR, Haidar CE, Hoffman JM, Baker DK, Barker PJ, Estepp JH, Pei D, Broeckel U, Wang W, Weiss MJ, Relling MV, Hankins J. Pharmacogenetics for Safe Codeine Use in Sickle Cell Disease. Pediatrics 2016; 138:peds.2015-3479. [PMID: 27335380 PMCID: PMC4925073 DOI: 10.1542/peds.2015-3479] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2016] [Indexed: 01/15/2023] Open
Abstract
After postoperative deaths in children who were prescribed codeine, several pediatric hospitals have removed it from their formularies. These deaths were attributed to atypical cytochrome P450 2D6 (CYP2D6) pharmacogenetics, which is also implicated in poor analgesic response. Because codeine is often prescribed to patients with sickle cell disease and is now the only Schedule III opioid analgesic in the United States, we implemented a precision medicine approach to safely maintain codeine as an option for pain control. Here we describe the implementation of pharmacogenetics-based codeine prescribing that accounts for CYP2D6 metabolizer status. Clinical decision support was implemented within the electronic health record to guide prescribing of codeine with the goal of preventing its use after tonsillectomy or adenoidectomy and in CYP2D6 ultra-rapid and poor metabolizer (high-risk) genotypes. As of June 2015, CYP2D6 genotype results had been reported for 2468 unique patients. Of the 830 patients with sickle cell disease, 621 (75%) had a CYP2D6 genotype result; 7.1% were ultra-rapid or possible ultra-rapid metabolizers, and 1.4% were poor metabolizers. Interruptive alerts recommended against codeine for patients with high-risk CYP2D6 status. None of the patients with an ultra-rapid or poor metabolizer genotype were prescribed codeine. Using genetics to tailor analgesic prescribing retained an important therapeutic option by limiting codeine use to patients who could safely receive and benefit from it. Our efforts represent an evidence-based, innovative medication safety strategy to prevent adverse drug events, which is a model for the use of pharmacogenetics to optimize drug therapy in specialized pediatric populations.
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Affiliation(s)
| | | | | | | | | | | | | | - Deqing Pei
- Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee; and
| | - Ulrich Broeckel
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
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14
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Chang AK, Bijur PE, Holden L, Gallagher EJ. Comparative Analgesic Efficacy of Oxycodone/Acetaminophen Versus Hydrocodone/Acetaminophen for Short-term Pain Management in Adults Following ED Discharge. Acad Emerg Med 2015; 22:1254-60. [PMID: 26479162 DOI: 10.1111/acem.12813] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 07/06/2015] [Accepted: 07/08/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The objective was to test the hypothesis that oxycodone/acetaminophen provides superior analgesia to hydrocodone/acetaminophen for the treatment of acute extremity pain following emergency department (ED) discharge. METHODS This was a prospective, randomized, double-blind clinical trial of nonelderly adult ED patients with acute musculoskeletal extremity pain, randomly allocated at discharge to receive oxycodone/acetaminophen (5 mg/325 mg) or hydrocodone/acetaminophen (5 mg/325 mg). The primary outcome was the between-group difference in improvement in numerical rating scale (NRS) pain scores over a 2-hour period following the most recent ingestion of study drug, obtained during telephone contact 24 hours after ED discharge. Secondary outcomes included proportionate decrease in pain, comparative side-effect profiles, and patient satisfaction. RESULTS A total of 240 patients were enrolled. The final sample consisted of 220 patients, 107 randomly allocated to oxycodone/acetaminophen and 113 to hydrocodone/acetaminophen. At 24 hours after ED discharge, the mean NRS pain scores prior to the most recent dose of outpatient pain medication were 7.8 and 7.9 in the oxycodone/acetaminophen and hydrocodone/acetaminophen groups, respectively. The mean decreases in pain scores over 2 hours were 4.4 NRS units in the oxycodone/acetaminophen group versus 4.0 NRS units in the hydrocodone/acetaminophen group, for a difference of 0.4 NRS units (95% confidence interval = -0.2 to 1.1 NRS units). Satisfaction with the analgesics was similar. CONCLUSIONS This study design could not detect a clinically or statistically significant difference in analgesic efficacy between oxycodone/acetaminophen (5 mg/325 mg) and hydrocodone/acetaminophen (5 mg/325 mg) for treatment of acute musculoskeletal extremity pain in adults following ED discharge. Both opioids reduced pain scores by approximately 50%.
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Affiliation(s)
- Andrew K. Chang
- Department of Emergency Medicine; Albert Einstein College of Medicine; Montefiore Medical Center; Bronx NY
| | - Polly E. Bijur
- Department of Emergency Medicine; Albert Einstein College of Medicine; Montefiore Medical Center; Bronx NY
| | - Lynne Holden
- Department of Emergency Medicine; Albert Einstein College of Medicine; Montefiore Medical Center; Bronx NY
| | - E. John Gallagher
- Department of Emergency Medicine; Albert Einstein College of Medicine; Montefiore Medical Center; Bronx NY
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15
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Qiu X, Lou D, Su D, Liu Z, Gao P, Zhang NS. Simultaneous determination of acetaminophen and dihydrocodeine in human plasma by UPLC-MS/MS: Its pharmacokinetic application. J Chromatogr B Analyt Technol Biomed Life Sci 2015; 992:91-5. [PMID: 25965875 DOI: 10.1016/j.jchromb.2015.04.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 04/16/2015] [Accepted: 04/18/2015] [Indexed: 01/17/2023]
Abstract
An ultra performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS) method was developed and validated to determine acetaminophen (AAP) and dihydrocodeine (DHC) in human plasma simultaneously. Plasma samples were prepared using protein precipitation with acetonitrile, the two analytes and the internal standard midazolam were separated on an Acquity UPLC BEH C18 column and mass spectrometric analysis was performed using a QTrap5500 mass spectrometer coupled with an electro-spray ionization (ESI) source in the positive ion mode. The MRM transitions of m/z 151.2→110.0 and m/z 302.3→199.2 were used to quantify for AAP and DHC, respectively. The linearity of this method was found to be within the concentration range of 50-10000ng/mL for AAP, and 1-100ng/mL for DHC in human plasma, respectively. The lower limit of quantification (LLOQ) was 50ng/mL and 1ng/mL for AAP and DHC in human plasma, respectively. The relative standard deviations (RSD) of intra and inter precision were less than 10% for both AAP and DHC. The analysis time of per sample was 1.0min. The developed and validated method was successfully applied to a pharmacokinetic study of AAP (500mg) with DHC (20mg) capsule in Chinese healthy volunteers (N=20).
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Affiliation(s)
- Xiangjun Qiu
- Medical College of Henan University of Science and Technology, Luoyang 471003, PR China
| | - Dan Lou
- The Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325027, PR China
| | - Ding Su
- Medical College of Henan University of Science and Technology, Luoyang 471003, PR China
| | - Zebin Liu
- Medical College of Henan University of Science and Technology, Luoyang 471003, PR China
| | - Pengtao Gao
- Medical College of Henan University of Science and Technology, Luoyang 471003, PR China
| | - Nan-sheng Zhang
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, PR China.
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Abstract
A recently published study in Pediatrics by Kaiser et al. (2014; Epub April 21, DOI: 10.1542/peds.2013-3171) reported that on average, over the past decade, children aged 3 to 17 were prescribed approximately 700,000 prescriptions for codeine-containing products each year in association with emergency department (ED) visits. Although, guidelines from the American Academy of Pediatrics issued warnings in 1997 and reaffirmed their concerns regarding the safety and effectiveness of codeine in 2006, it is still often prescribed for pain and cough associated with upper respiratory infection. With the impending rescheduling of hydrocodone combination products to Schedule II, physicians and mid-level prescribers may be compelled to prescribe codeine-containing products (e.g., with acetaminophen) due to reduced administrative burden and limits on Schedule II prescriptive authority for nurse practitioners and physician assistants in some states. This commentary expounds on the safety and effectiveness concerns of codeine, with a primary focus on patients in the ED setting.
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Perrone J, Mycyk MB. A challenging crossroad for emergency medicine: the epidemics of pain and pain medication deaths. Acad Emerg Med 2014; 21:334-6. [PMID: 24761457 DOI: 10.1111/acem.12323] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - Mark B. Mycyk
- Academic Emergency Medicine; Cook County Hospital; Chicago IL
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