Use of opiates for musculoskeletal pain relief in emergency department (ED) patients is no better than non-steroids anti-inflammatory drugs
Opiates and non-steroidal anti-inflammatory drugs (NSAIDs) provide a similar level of pain relief for patients with musculoskeletal pain who present at an emergency department according to the findings of a meta-analysis by researchers from Sydney, Australia.
Opiates can be prescribed to patients within an emergency department (ED) who present with pain though one US study suggested that most opioid prescribing originates from primary care with a smaller proportion from EDs. However, other studies indicate that opiates (opioids) are probably used more often especially since in a 2020 study of an Australian tertiary hospital in Victoria, concluded that opioid prescribing was common with almost one-quarter of discharge prescriptions being for a prescription opioid. In another study, this time from a US hospital, of 19,321 discharged patients, 17% received an opioid pain reliever prescription. The value of opioids in the management of musculoskeletal pain was addressed in a 2020 American College of Physicians and American Academy of Family Physicians clinical guide and which clearly advises ‘against clinicians treating patients with acute pain from non–low back, musculoskeletal injuries with opioids, including tramadol.‘ The comparative efficacy of opiates and other analgesics in non-low back, musculoskeletal injuries were examined in a 2020 systematic review which concluded on how no opioid achieved benefit greater than that of NSAIDs, adding how opioids caused the most harms. Nevertheless, there is a lack of data on the efficacy of opiates for relief of musculoskeletal pain within an ED setting. Consequently, the Australian team decided to evaluate the effectiveness and safety of opioid analgesics compared with placebo, paracetamol and other non-opiates during an ED stay. The team searched all of the major databases and included randomised, controlled trials in adults with musculoskeletal pain (e.g., sprains, muscle aches, ligament, tendons, bone in the case of fractures) who attended an ED. They set the primary outcome as pain intensity at follow-up of approximately 2 hours after administration of treatment and which was measured on a 100 mm visual analogue scale.
Opiates and comparative pain relief
A total of 42 articles with 5765 participants and a mean age of 41 years (37.6% female) were included in the analysis.
The reduction in pain relief from opiates after 2 hours, was statistically superior to placebo (mean difference, MD = -6.3, 95% CI -10.5 to -2.2) and paracetamol (MD = -6.7, 95% CI -11.9 to -1.5). However, the difference with NSAIDs was not significant (MD = -0.1, 95% CI -2.5 to 2.3) although opioids were far less effective than local anaesthetics (MD = 17.3, 95% CI 1.5 to 33.1). Overall, there was no evidence of a clinical or statistical difference between opioids and non-opioids for pain relief at either 0.5 or 12 hours after dosing.
With respect to adverse events, opioid patients were at a higher risk than those receiving placebo (14%), paracetamol (7.2%) or NSAIDs (21.4%).
Despite these findings, the authors concluded that the risk-benefit balance of opiates compared to placebo, paracetamol, NSAIDs and local anaesthetics remains uncertain. They added that while opiates have equivalent pain outcomes to NSAIDs, the evidence on harm is uncertain and heterogenous.
Jones CMP et al. Effectiveness of Opioid Analgesic Medicines Prescribed in or at Discharge From Emergency Departments for Musculoskeletal Pain : A Systematic Review and Meta-analysis Ann Intern Med 2022