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Friedman BW, Chen YT, Campbell C, Nerenberg R, Afrifa F, Schimmrich K, Adewunmi V, Baer J, Irizarry E. A sequential, multiple-assignment, randomized trial of analgesic strategies for acute musculoskeletal Pain. Am J Emerg Med 2024; 82:15-20. [PMID: 38749371 PMCID: PMC11254572 DOI: 10.1016/j.ajem.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/11/2024] [Accepted: 05/06/2024] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND Most methodologically rigorous, ED-based, comparative effectiveness analgesic studies completed in the last two decades failed to find a clinically important difference between the comparators. We believe that many of these comparative effectiveness studies were biased towards the null hypothesis because some ED patients with intense pain will respond to relatively mild interventions. We hypothesized that including a run-in period would alter the results of an acute pain RCT. METHODS We conducted a sequential, multiple-assignment, randomized study. Adults with acute moderate/severe musculoskeletal pain were randomized (3:1 ratio) to run-in period or no run-in. We administered 650 mg acetaminophen to run-in participants. Those run-in patients who reported insufficient relief one-hour later were randomized (1:1 ratio) to ibuprofen 800mg PO or ketorolac 20mg PO as were all participants randomized to no run-in. The primary outcome was achieving a clinically important improvement, defined as improvement ≥1.3 on a 0-10 scale. We built a logistic regression model including run-in/no run-in, ketorolac/ibuprofen, age and sex. RESULTS Of 307 participants who received acetaminophen, 100 (32.6%) reported inadequate relief and were randomized to an NSAID. Of the 100 patients randomized to no run-in, 84/100 (84%) achieved the primary outcome versus 246/287 (86%) run-in participants (95% CI for difference = 2%:-7,10%). Among run-in participants who received an NSAID, 82/99(83%) achieved the primary outcome versus 84/100(84%) no run-in participants (p = 0.82). Among all ibuprofen participants, 44/49(90%) randomized to run-in and 42/50(84%) randomized to no run-in achieved the primary outcome. Among all ketorolac participants, 38/50(76%) randomized to run-in and 42/50 (84%) randomized to no run-in achieved the primary outcome. We observed the following results in a multivariable analysis: OR for ketorolac versus ibuprofen:0.60 (95% CI: 0.28, 1.28); OR for run-in versus no run-in:0.91(95% CI: 0.43, 1.93). CONCLUSIONS Among patients with acute musculoskeletal pain, using an acetaminophen first strategy did not alter pain outcomes.
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Affiliation(s)
- Benjamin W Friedman
- Department of Emergency Medicine, Montefiore-Einstein, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Yen Ting Chen
- Department of Emergency Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Caron Campbell
- Department of Emergency Medicine, Montefiore-Einstein, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Rebecca Nerenberg
- Department of Emergency Medicine, Montefiore-Einstein, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Freda Afrifa
- Pharmacy Department, Montefiore-Einstein, Bronx, NY, USA
| | - Kristen Schimmrich
- Department of Emergency Medicine, Montefiore-Einstein, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Victoria Adewunmi
- Department of Emergency Medicine, Montefiore-Einstein, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jesse Baer
- Department of Emergency Medicine, Montefiore-Einstein, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Eddie Irizarry
- Department of Emergency Medicine, Montefiore-Einstein, Albert Einstein College of Medicine, Bronx, NY, USA
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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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Li Y, An M, Ding Y, Wang C, Qiu Y. Oxycodone-acetaminophen versus celecoxib for postoperative pain in knee osteoarthritis patients after total knee arthroplasty: a randomized, controlled study. Arch Orthop Trauma Surg 2023; 143:6753-6762. [PMID: 37344688 DOI: 10.1007/s00402-023-04943-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 06/04/2023] [Indexed: 06/23/2023]
Abstract
PURPOSE Oxycodone-acetaminophen is a synergic combination of semisynthetic opioid agonis and analgesic/antipyretic agent, which improves analgesic efficacy. This randomized, controlled study intended to evaluate the analgesic efficacy and tolerance of oxycodone-acetaminophen compared to celecoxib alone in post-total knee arthroplasty (TKA) knee osteoarthritis patients. METHODS One hundred and six knee osteoarthritis patients were randomized into oxycodone-acetaminophen group (N = 54) and celecoxib group (N = 52) at a 1:1 ratio. Each patient orally received oxycodone-acetaminophen (5 mg/325 mg, four times per day) or celecoxib (200 mg, twice per day) from 2 h to day (D) 3 after TKA; meanwhile, each patient received 2-day patient-controlled analgesia (PCA). The primary outcome was pain visual analog scale (VAS) score at rest; other assessments were the secondary outcomes. RESULTS Pain VAS scores at rest at D1, D2, D3, and pain VAS scores at flexion at D0.5, D1, D2, D3 were lower in oxycodone-acetaminophen group compared to celecoxib group (all P < 0.050). Besides, extra (P < 0.001) and total (P < 0.001) PCA consumption were declined in oxycodone-acetaminophen group compared with celecoxib group. Furthermore, patients' satisfaction score at D3 (P = 0.012) and D7 (P = 0.043) was higher in oxycodone-acetaminophen group versus celecoxib group. Hospital for special surgery knee score (HSS) at preoperation, M1, and M3 did not differ between the two groups (all P > 0.050). The incidences of all adverse events were not varied between oxycodone-acetaminophen and celecoxib groups (all P > 0.050). CONCLUSION Oxycodone-acetaminophen exerts superior analgesic efficacy, patients' satisfaction, and similar tolerance compared to celecoxib in post-TKA knee osteoarthritis patients.
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Affiliation(s)
- Yating Li
- Department of Anesthesia, The Second Affiliated Hospital of Inner Mongolia Medical University, No. 59 Kerqin South Road, Hohhot, 010020, China
| | - Min An
- Department of Anesthesia, The Second Affiliated Hospital of Inner Mongolia Medical University, No. 59 Kerqin South Road, Hohhot, 010020, China
| | - Yumei Ding
- Department of Anesthesia, The Second Affiliated Hospital of Inner Mongolia Medical University, No. 59 Kerqin South Road, Hohhot, 010020, China
| | - Caixia Wang
- Department of Anesthesia, The Second Affiliated Hospital of Inner Mongolia Medical University, No. 59 Kerqin South Road, Hohhot, 010020, China
| | - Yi Qiu
- Department of Anesthesia, The Second Affiliated Hospital of Inner Mongolia Medical University, No. 59 Kerqin South Road, Hohhot, 010020, China.
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Weiner SG, Hendricks MA, El Ibrahimi S, Ritter GA, Hallvik SE, Hildebran C, Weiss RD, Boyer EW, Flores DP, Nelson LS, Kreiner PW, Fischer MA. Opioid-related overdose and chronic use following an initial prescription of hydrocodone versus oxycodone. PLoS One 2022; 17:e0266561. [PMID: 35381052 PMCID: PMC8982846 DOI: 10.1371/journal.pone.0266561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 03/22/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Hydrocodone and oxycodone are prescribed commonly to treat pain. However, differences in risk of opioid-related adverse outcomes after an initial prescription are unknown.
This study aims to determine the risk of opioid-related adverse events, defined as either chronic use or opioid overdose, following a first prescription of hydrocodone or oxycodone to opioid naïve patients.
Methods
A retrospective analysis of multiple linked public health datasets in the state of Oregon. Adult patients ages 18 and older who a) received an initial prescription for oxycodone or hydrocodone between 2015–2017 and b) had no opioid prescriptions or opioid-related hospitalizations or emergency department visits in the year preceding the prescription were followed through the end of 2018. First-year chronic opioid use was defined as ≥6 opioid prescriptions (including index) and average ≤30 days uncovered between prescriptions. Fatal or non-fatal opioid overdose was indicated from insurance claims, hospital discharge data or vital records.
Results
After index prescription, 2.8% (n = 14,458) of individuals developed chronic use and 0.3% (n = 1,480) experienced overdose. After adjustment for patient and index prescription characteristics, patients receiving oxycodone had lower odds of developing chronic use relative to patients receiving hydrocodone (adjusted odds ratio = 0.95, 95% confidence interval (CI) 0.91–1.00) but a higher risk of overdose (adjusted hazard ratio (aHR) = 1.65, 95% CI 1.45–1.87). Oxycodone monotherapy appears to greatly increase the hazard of opioid overdose (aHR 2.18, 95% CI 1.86–2.57) compared with hydrocodone with acetaminophen. Oxycodone combined with acetaminophen also shows a significant increase (aHR 1.26, 95% CI 1.06–1.50), but not to the same extent.
Conclusions
Among previously opioid-naïve patients, the risk of developing chronic use was slightly higher with hydrocodone, whereas the risk of overdose was higher after oxycodone, in combination with acetaminophen or monotherapy. With a goal of reducing overdose-related deaths, hydrocodone may be the favorable agent.
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Affiliation(s)
- Scott G. Weiner
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Michelle A. Hendricks
- Division of Research and Evaluation, Comagine Health, Portland, Oregon, United States of America
| | - Sanae El Ibrahimi
- Division of Research and Evaluation, Comagine Health, Portland, Oregon, United States of America
- Department of Epidemiology and Biostatistics, School of Public Health, University of Nevada, Las Vegas, Las Vegas, Nevada, United States of America
| | - Grant A. Ritter
- Brandeis University, Waltham, Massachusetts, United States of America
| | - Sara E. Hallvik
- Division of Research and Evaluation, Comagine Health, Portland, Oregon, United States of America
| | - Christi Hildebran
- Division of Research and Evaluation, Comagine Health, Portland, Oregon, United States of America
| | - Roger D. Weiss
- Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Psychiatry, McLean Hospital, Belmont, Massachusetts, United States of America
| | - Edward W. Boyer
- Department of Emergency Medicine, Ohio State University, Columbus, Ohio, United States of America
| | - Diana P. Flores
- Division of Research and Evaluation, Comagine Health, Portland, Oregon, United States of America
| | - Lewis S. Nelson
- Department of Emergency Medicine Rutgers New Jersey Medical School, Newark, New Jersey, United States of America
| | - Peter W. Kreiner
- Brandeis University, Waltham, Massachusetts, United States of America
| | - Michael A. Fischer
- Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States of America
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Friedman BW. Peripheral Nerve Blocks for Headache: A Precise Approach to Pain Management in the Emergency Department. Ann Emerg Med 2021; 79:262-264. [PMID: 34952731 DOI: 10.1016/j.annemergmed.2021.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Indexed: 11/01/2022]
Affiliation(s)
- Benjamin W Friedman
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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Palochak CMA, Reed DS, Apsey DA, Legault GL, Carlton D, Caldwell MC, Townley JR, Madsen MH, Evangelista CB. Pain Control Following Photorefractive Keratectomy: A Prospective Clinical Trial Comparing Codeine Versus Oxycodone for the Management of Postoperative Pain. J Refract Surg 2021; 37:582-589. [PMID: 34506240 DOI: 10.3928/1081597x-20210701-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE To compare the efficacy of oral codeine plus acetaminophen versus oxycodone plus acetaminophen for severe pain control following photorefractive keratectomy (PRK). METHODS This single-center trial randomized 200 patients to receive codeine 30 mg/acetaminophen 325 mg (codeine group) or oxycodone 5 mg/acetaminophen 325 mg (oxycodone group)every 4 hours as needed for severe pain for 4 days following PRK. Patients recorded postoperative pain, tablet consumption, and tetracaine use. Patients were monitored at postoperative 1 day, 1 week, and 1, 3, and 6 months for visual acuity and follow-up. Study outcomes were mean postoperative pain, treatment and tetracaine use, and visual acuity. RESULTS Analysis of 197 patients who completed the trial (97 codeine group and 100 oxycodone group) showed mean pain scores were lower in the codeine group throughout the intervention period. Mean pain scores were higher in the oxycodone group than the codeine group on postoperative days 2 and 4 (P = .017 and P = .034, respectively). The oxycodone group consumed more tablets than the codeine group, with a difference on postoperative day 2 (P = .019), and used a greater number of tetracaine drops (P = .015). Repeated measures analysis of variance showed significant improvement in visual acuity in both groups with no difference in visual outcomes (P = .81). CONCLUSIONS Codeine/acetaminophen is as effective and safe as oxycodone/acetaminophen for pain control following PRK, with no clinical difference in overall pain control and long-term visual outcomes. This implies that treating postoperative pain after PRK with a Schedule III opioid (codeine) is effective and potentially decreases the risk of misuse by a higher regulated Schedule II opioid (oxycodone), lowering the potential for abuse and dependence. [J Refract Surg. 2021;37(9):582-589.].
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Richard P, Bauer MR, Moresco N, Walker R, Bowser D, Reed D, Larson MJ. Opioid prescribing for surgical dental procedures in dental clinics of military treatment facilities. J Am Dent Assoc 2020; 152:94-104.e18. [PMID: 33358238 DOI: 10.1016/j.adaj.2020.09.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 09/04/2020] [Accepted: 09/21/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Variation in opioid prescribing rates among geographic regions is well known and, to the authors' knowledge, there have been no studies of variation from 1 dental clinic to another, and such variation might suggest an excess of opioid prescriptions. METHODS The authors used a retrospective cohort design study of all dental encounter records for 819,453 soldiers in the dental clinics (n = 250) of the US Military Health System during the period from 2008 through 2017. RESULTS There were 743,459 dental surgical encounters. Opioid prescriptions were filled for 36.7% of these encounters. Multinomial multilevel regression found statistically significant between-facility variance in opioid prescribing, which was partially explained via facility-level characteristics (region, type, and percentage of surgeries for young patients), and practice variables (mean percentage extractions, percentage periodontic surgery, and percentage specialists). CONCLUSIONS The authors found a substantial variation in opioid prescribing among dental clinics in the US Military Health System. Dentists at 11 of the 30 largest military treatment facilities prescribed at a rate 4 percentage points higher than expected, and dentists at 9 of these military treatment facilities had a rate of 4 percentage points lower than expected. Additional study of the factors allowing the low-prescribing facilities to achieve these rates might lead to an overall decrease in opioid prescribing. PRACTICAL IMPLICATIONS The authors' findings of dental opioid prescribing in the military can lead to appreciation of the guidelines from the American Dental Association and the American Association of Oral and Maxillofacial Surgeons, which suggest alternatives to opioid prescribing for surgical procedures, particularly for tooth extractions.
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Donohoe GC, Zhang B, Mensinger JL, Litman RS. Trends in Postoperative Opioid Prescribing in Outpatient Pediatric Surgery. PAIN MEDICINE 2020; 20:1789-1795. [PMID: 30657976 DOI: 10.1093/pm/pny284] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine trends in opioid prescribing for home use after pediatric outpatient surgery. DESIGN Retrospective analysis of a de-identified database. SETTING Multispecialty children's hospital and freestanding surgery centers. PATIENTS, PARTICIPANTS A total of 65,190 encounters of pediatric outpatient surgeries from 2013 through 2017 for nine different surgical specialties. Patients in the cardiothoracic service and nonpainful procedures were excluded. MAIN Outcome Measures. Incidence rate of prescribing, dose, number of doses available (i.e., duration of therapy), and maximum weight-based home opioid availability from 2013 to 2017. Additional independent variables included sex, age, weight, race/ethnicity, insurance type (private vs public), and surgical service. RESULTS The incidence rate of receiving a take-home opioid prescription at discharge ranged from 18% to 21% between 2013 and 2017, with no clear directional trend. Among patients prescribed opioids, however, the maximum available take-home dose steadily declined from 2013 through 2017 (P < 0.001). This was due to both a decrease in the number of doses prescribed (i.e., duration of treatment) and, beginning in 2015, the amount per dose. Females were more likely to receive an opioid than males, and patients with public insurance were more likely to receive an opioid than those with private insurance. Opioid prescribing was more likely in patients who did not disclose their ethnicity and those of ethnic minority compared with white patients (all P < 0.0001). CONCLUSIONS The rate of receiving a take-home opioid prescription and the dose prescribed remained stable from 2013 to 2017, but the duration of treatment steadily declined, and beginning in 2015, the amount per dose also decreased. Certain subgroups of patients were more likely to be prescribed opioids and will require further investigation and confirmation.
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Affiliation(s)
- Gabrielle C Donohoe
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Drexel University, Philadelphia, Pennsylvania
| | - Bingqing Zhang
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Janell L Mensinger
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Ronald S Litman
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Institute for Safe Medication Practices, Horsham, Pennsylvania, USA
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Kim HS, Courtney DM, McCarthy DM, Cella D. Patient-reported Outcome Measures in Emergency Care Research: A Primer for Researchers, Peer Reviewers, and Readers. Acad Emerg Med 2020; 27:403-418. [PMID: 31945245 DOI: 10.1111/acem.13918] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/04/2020] [Accepted: 01/06/2020] [Indexed: 01/07/2023]
Abstract
Patient-reported outcomes (PROs) are of increasing importance in clinical research because they capture patients' experience with well-being, illness, and their interactions with health care. Because PROs tend to focus on specific symptoms (e.g., pain, anxiety) or general assessments of patient functioning and quality of life that offer unique advantages compared to traditional clinical outcomes (e.g., mortality, emergency department revisits), emergency care researchers may benefit from incorporation of PRO measures into their research design as a primary or secondary outcome. Patients may also benefit from the ability of PROs to inform clinical practice and facilitate patient decision making, as PROs are obtained directly from the lived experience of other patients with similar conditions or health status. This review article introduces and defines key terminology relating to PROs, discusses reasons for utilizing PROs in clinical research, outlines basic psychometric and practical assessments that can be used to select a specific PRO measure, and highlights examples of commonly utilized PRO measures in emergency care research.
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Affiliation(s)
- Howard S. Kim
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago IL
- Center for Health Services & Outcomes Research Northwestern University Feinberg School of Medicine Chicago IL
| | - D. Mark Courtney
- Department of Emergency Medicine University of Texas Southwestern Medical School Dallas TX
| | - Danielle M. McCarthy
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago IL
- Center for Health Services & Outcomes Research Northwestern University Feinberg School of Medicine Chicago IL
| | - David Cella
- Department of Medical Social Sciences Northwestern University Feinberg School of Medicine Chicago IL
- Center for Patient‐Centered Outcomes Northwestern University Feinberg School of Medicine Chicago IL
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Menchine M, Lam CN, Arora S. Prescription Opioid Use in General and Pediatric Emergency Departments. Pediatrics 2019; 144:peds.2019-0302. [PMID: 31619511 DOI: 10.1542/peds.2019-0302] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Recent evidence reveals that exposure to emergency department (ED) opioids is associated with a higher risk of misuse. Pediatric EDs are generally thought to provide the highest-quality care for young persons, but most children are treated in general EDs. We sought to determine if ED opioid administration and prescribing vary between pediatric and general EDs. METHODS We analyzed the National Hospital Ambulatory Medical Care Survey (2006-2015), a representative survey of ED visits, by using multivariate logistic regressions. Outcomes of interest were the proportion of patients ≤25 years of age who (1) were administered an opioid in the ED, (2) were given a prescription for an opioid, or (3) were given a prescription for a nonopioid analgesic. The key predictor variable was ED type. A secondary analysis was conducted on the subpopulation of patients with a diagnosis of fracture or dislocation. RESULTS Of patients ≤25 years of age, 91.1% were treated in general EDs. The odds of being administered an opioid in the ED were similar in pediatric versus general EDs (adjusted odds ratio [OR] 0.88; 95% confidence interval [CI] 0.61-1.27; P = .49). Patients seen in pediatric EDs were less likely to receive an outpatient prescription for opioids (adjusted OR 0.38; 95% CI 0.27-0.52; P < .01) than similar patients in general EDs. This was true for the fracture subset as well (adjusted OR 0.27; 95% CI 0.13-0.54; P < .01). CONCLUSIONS Although children, adolescents, and young adults had similar odds of being administered opioids while in the ED, they were much less likely to receive an opioid prescription from a pediatric ED compared with a general ED.
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Affiliation(s)
- Michael Menchine
- Keck School of Medicine, University of Southern California and LAC + USC Medical Center, Los Angeles, California
| | - Chun Nok Lam
- Keck School of Medicine, University of Southern California and LAC + USC Medical Center, Los Angeles, California
| | - Sanjay Arora
- Keck School of Medicine, University of Southern California and LAC + USC Medical Center, Los Angeles, California
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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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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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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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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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Duffy KJ, Flickinger KL, Kristan JT, Repine MJ, Gianforcaro A, Hasley RB, Feroz S, Rupp JM, Al-Baghli J, Pacella ML, Suffoletto BP, Callaway CW. Quantitative sensory testing measures individual pain responses in emergency department patients. J Pain Res 2017; 10:1241-1253. [PMID: 28579822 PMCID: PMC5449126 DOI: 10.2147/jpr.s132485] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background Refining and individualizing treatment of acute pain in the emergency department (ED) is a high priority, given that painful complaints are the most common reasons for ED visits. Few tools exist to objectively measure pain perception in the ED setting. We speculated that variation in perception of fixed painful stimuli would explain individual variation in reported pain and response to treatment among ED patients. Materials and methods In three studies, we 1) describe performance characteristics of brief quantitative sensory testing (QST) in 50 healthy volunteers, 2) test effects of 10 mg oxycodone versus placebo on QST measures in 18 healthy volunteers, and 3) measure interindividual differences in nociception and treatment responses in 198 ED patients with a painful complaint during ED treatment. QST measures adapted for use in the ED included pressure sensation threshold, pressure pain threshold (PPT), pressure pain response (PPR), and cold pain tolerance (CPT) tests. Results First, all QST measures had high inter-rater reliability and test–retest reproducibility. Second, 10 mg oxycodone reduced PPR, increased PPT, and prolonged CPT. Third, baseline PPT and PPR revealed hyperalgesia in 31 (16%) ED subjects relative to healthy volunteers. In 173 (88%) ED subjects who completed repeat testing 30 minutes after pain treatment, PPT increased and PPR decreased (Cohen’s dz 0.10–0.19). Verbal pain scores (0–10) for the ED complaint decreased by 2.2 (95% confidence intervals [CI]: 1.9, 2.6) (Cohen’s dz 0.97) but did not covary with the changes in PPT and PPR (r=0.05–0.13). Treatment effects were greatest in ED subjects with a history of treatment for anxiety or depression (Cohen’s dz 0.26–0.43) or with baseline hyperalgesia (Cohen’s dz 0.40–0.88). Conclusion QST reveals individual differences in perception of fixed painful stimuli in ED patients, including hyperalgesia. Subgroups of ED patients with hyperalgesia and psychiatric history report larger treatment effects on ED pain and QST measures.
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Affiliation(s)
- Kevin J Duffy
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Katharyn L Flickinger
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffrey T Kristan
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Melissa J Repine
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alexandro Gianforcaro
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rebecca B Hasley
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Saad Feroz
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jessica M Rupp
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jumana Al-Baghli
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Maria L Pacella
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian P Suffoletto
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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