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Opioids and non-opioid analgesics may work equally in the ER, but questions remain

Rating

3 Star

No significant difference in pain relief for opioids vs. non-opioid analgesics for treating arm or leg pain

Our Review Summary

ER team, emergency roomThe release focuses on a recent study, published in JAMA, that evaluated the effectiveness of four painkillers in addressing acute arm or leg pain in emergency room patients. One of the painkillers was a combination of the over-the-counter medications acetaminophen and ibuprofen; the other three painkillers were combinations of acetaminophen and an opioid (oxycodone, hydrocodone or codeine). The study found that — within the two-hour window being evaluated — there was no statistical significant difference in the effectiveness of the four drugs, indicating that acetaminophen/ibuprofen is a viable alternative to opioids for addressing acute pain. The release does a good job of describing the study and placing it in the context of the “opioid crisis” in the U.S. However, the release does not address cost or potential harms, and does not make clear how this study builds on or differs from previous research on how non-opioid painkillers differ from opioid painkillers.

 

Why This Matters

As the news release notes, “the United States is facing an opioid epidemic.” According to the American Society of Addiction Medicine, at least 2 million Americans had an addiction to prescription painkillers in 2015 — and more than 20,000 people died from prescription painkiller overdoses in the same year. And data from the National Institute of Drug Abuse show that this problem is on the rise. In other words, the subject matter is timely and important. But patients and healthcare providers also deserve a little additional context for this work. Is this the first study to compare non-opioid and opioid painkillers? The release doesn’t tell us. (It’s not.) How do they compare on cost? Is the non-opioid option risk free? These are important questions, and ones that could be addressed quickly. The release would have been stronger if it had done so.

An editorial in JAMA editorial notes that the ibuprofen-acetaminophen combination has been studied and used more in other countries, and that many people get their first opioid prescription from the ER, so cutting down on opioid use and distribution from ERs could make a significant dent in the epidemic. This was a main reason for the study.

Criteria

Does the news release adequately discuss the costs of the intervention?

Not Satisfactory

Costs are not discussed. The costs of ibuprofen and acetaminophen are fairly low — but the relevant opioids are also relatively inexpensive. For the relevant dosages, the costs would be more or less comparable, with the hydrocodone/acetaminophen combination likely being the most expensive.

Does the news release adequately quantify the benefits of the treatment/test/product/procedure?

Satisfactory

This is a tough one, since the release does not quantify the extent of the pain reduction. The release notes only that “After 2 hours pain was less in all participants, without any important difference in effect between the four groups.” There were differences between the groups, but those differences were not statistically significant. However, given that we often call out news releases that make a big deal out of statistically insignificant differences, we approve of the way that issue is handled here — thus the satisfactory rating.

Does the news release adequately explain/quantify the harms of the intervention?

Not Satisfactory

The release does address the harms associated with the use (or misuse) of opioid analgesics. However, the release doesn’t address the potential harms from ibuprofen or acetaminophen in a meaningful way. The closest it comes is a sentence noting that “further research to assess longer-term effect, adverse events and dosing is warranted.” But there are some things we already know. As the Mayo Clinic notes, ibuprofen use may increase risk of heart attack or stroke, and may also cause stomach or intestinal bleeding. And acetaminophen can harm the liver if taken in too large a quantity. Granted, the risk of these things is low — particularly if it is used only in the short term to address acute pain — but it would have been relatively easy to address.

The JAMA study didn’t assess harms either; still a statement to this effect could have been made.

Does the news release seem to grasp the quality of the evidence?

Satisfactory

The release does a pretty good job of describing the study and explaining the strengths (and weaknesses) of randomized clinical trials like this one. It would have been a little stronger if it had explained how pain was measured. The one error we’ll point out is that the release refers to the study population as consisting of 416 patients. The paper makes clear that five of those patients were excluded from the analysis because they had already taken analgesics before treatment at the emergency room, meaning that the relevant study population was actually 411 patients. It’s an easy mistake to make, but it’s a mistake.

Does the news release commit disease-mongering?

Satisfactory

No disease mongering here.

Does the news release identify funding sources & disclose conflicts of interest?

Not Satisfactory

The release says only that information about financial disclosures and funding are available in the JAMA article itself — which isn’t very helpful. For the record, the study was funded (at least in part) by the National Institute on Aging, and there don’t appear to be any conflicts of interest — but the news release could have said as much.

Does the news release compare the new approach with existing alternatives?

Satisfactory

The entire release (and the study it is discussing) are based on the comparison of alternatives for addressing acute pain in an emergency room environment.

Does the news release establish the availability of the treatment/test/product/procedure?

Satisfactory

The release does not address this explicitly, but it is fairly clear from the context that all of these painkillers are already clinically available.

Does the news release establish the true novelty of the approach?

Not Satisfactory

The release does not discuss any previous research in this area, nor does it make clear what sets this work apart from previous research. This is a significant oversight. As the paper itself notes: “Relatively few ED [emergency department] studies have compared the efficacy of the 3 most commonly used opioid analgesics in the ED and none has compared them in a single study. Although opioids are considered to provide stronger analgesia than nonopioid analgesics, 1 ED-based study found that adding combination oxycodone and acetaminophen to naproxen did not improve pain relief at 1 week in patients with acute low back pain. Several postsurgical studies have found combination nonopioids to be as effective as a combination of codeine and acetaminophen.” This is really useful information. Among other things, it tells us that previous studies have found similar results — but not in the context of addressing acute pain in the emergency room. In other words, it makes clear how this study builds on and is different from earlier research. That’s important.

Total Score: 6 of 10 Satisfactory

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