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Weiner SG, Hoppe JA. Contextualising opioid-related risk factors before an initial opioid prescription. BMJ Qual Saf 2023; 33:1-3. [PMID: 37500564 PMCID: PMC10817995 DOI: 10.1136/bmjqs-2023-016336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 07/29/2023]
Affiliation(s)
- Scott G Weiner
- Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jason A Hoppe
- Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Daoust R, Paquet J, Marquis M, Williamson D, Fontaine G, Chauny JM, Frégeau A, Orkin AM, Upadhye S, Lessard J, Cournoyer A. Efficacy of prescribed opioids for acute pain after being discharged from the emergency department: A systematic review and meta-analysis. Acad Emerg Med 2023; 30:1253-1263. [PMID: 37607265 DOI: 10.1111/acem.14790] [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: 04/27/2023] [Revised: 07/21/2023] [Accepted: 08/08/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Opioids are often prescribed for acute pain to patients discharged from the emergency department (ED), but there is a paucity of data on their short-term use. The purpose of this study was to synthesize the evidence regarding the efficacy of prescribed opioids compared to nonopioid analgesics for acute pain relief in ED-discharged patients. METHODS MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL, and gray literature databases were searched from inception to January 2023. Two independent reviewers selected randomized controlled trials investigating the efficacy of prescribed opioids for ED-discharged patients, extracted data, and assessed risk of bias. Authors were contacted for missing data and to identify additional studies. The primary outcome was the difference in pain intensity scores or pain relief. All meta-analyses used a random-effect model and a sensitivity analysis compared patients treated with codeine versus those treated with other opioids. RESULTS From 5419 initially screened citations, 46 full texts were evaluated and six studies enrolling 1161 patients were included. Risk of bias was low for five studies. There was no statistically significant difference in pain intensity scores or pain relief between opioids versus nonopioid analgesics (standardized mean difference [SMD] 0.12; 95% confidence interval [CI] -0.10 to 0.34). Contrary to children, adult patients treated with opioid had better pain relief (SMD 0.28, 95% CI 0.13-0.42) compared to nonopioids. In another sensitivity analysis excluding studies using codeine, opioids were more effective than nonopioids (SMD 0.30, 95% CI 0.15-0.45). However, there were more adverse events associated with opioids (odds ratio 2.64, 95% CI 2.04-3.42). CONCLUSIONS For ED-discharged patients with acute musculoskeletal pain, opioids do not seem to be more effective than nonopioid analgesics. However, this absence of efficacy seems to be driven by codeine, as opioids other than codeine are more effective than nonopioids (mostly NSAIDs). Further prospective studies on the efficacy of short-term opioid use after ED discharge (excluding codeine), measuring patient-centered outcomes, adverse events, and potential misuse, are needed.
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Affiliation(s)
- Raoul Daoust
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherce, Hôpital du Sacré-Cœur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
| | - Jean Paquet
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
| | - Martin Marquis
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
| | - David Williamson
- Centre de Recherce, Hôpital du Sacré-Cœur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
- Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada
| | - Guillaume Fontaine
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jean-Marc Chauny
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherce, Hôpital du Sacré-Cœur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
| | - Amélie Frégeau
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
| | - Aaron M Orkin
- Department of Family and Community Medicine and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Medicine, St. Joseph's Health Centre, Unity Health, Toronto, Ontario, Canada
| | - Suneel Upadhye
- McMaster University, Division of Emergency Medicine, Hamilton, Ontario, Canada
| | - Justine Lessard
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherce, Hôpital du Sacré-Cœur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
| | - Alexis Cournoyer
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherce, Hôpital du Sacré-Cœur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
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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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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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Xiang C, Pan M, Shen Q, Hu S, Feng Z, Feng Q, Yang C. Clinical Consumption of Compound Opioid Analgesics in China: A Retrospective Analysis of National Data 2015-2018. Biol Pharm Bull 2021; 44:1316-1322. [PMID: 34219120 DOI: 10.1248/bpb.b21-00347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Compound opioid analgesics (COA) are widely used for cancer pain relief, but few studies investigated the use of that. We aimed to report the characteristics and trend of COA consumption in different regions and health facilities in China. The procurement data of two types of COA, compound codeine phosphate (CCP) and oxycodone and acetaminophen (OAA), in all medical institutions of 20 provinces from 2015 to 2018 were used. Data were presented as defined daily dose for statistical purpose (SDDD) and expenditures per million inhabitants per day. The annual consumption of COA and ratio of two combinations were compared among regions and institutions. We found, during 2015-2018, COA consumption increased at an average rate of 7.32% in SDDD and 19.19% in expenditures, while OAA accounted for most of the consumption. Highest COA consumption appeared in Northern China, with 121.72 SDDD and 1689.87 RMB (2015), whereas the lowest COA consumption was only 11.28 SDDD appearing in Southern China. The ratio of OAA and CCP (in SDDD) was highest in Southern China (53.14 in 2018), whereas lowest in West North (0.37 in 2018). In terms of institutions, tertiary had the highest COA consumption, with 16.74 SDDD and 292.73 RMB (2018). The SDDD of OAA was 27.44 times of that of CCP in tertiary, while it was only 0.11 in primary. Overall, COA consumption is on an upward trend and different among regions and health institutions in either amount or types of COA. These findings call for establishment of COA management regulations.
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Affiliation(s)
- Cheng Xiang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University
| | - Mengyuan Pan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University
| | - Qian Shen
- The Second Affiliated Hospital, Xi'an Jiaotong University
| | - Shuchen Hu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University
| | - Zhitong Feng
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University
| | - Qinqin Feng
- Department of Pharmacy, No. 521 Hospital of Norinco Group
| | - Caijun Yang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University
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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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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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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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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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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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