Tailored opioid prescriptions for acute pain at ED discharge can reduce risk of misuse

2nd October 2023

Tailoring opioid prescriptions for patients discharged from an emergency department (ED) with acute pain can support recovery and help to avoid the risk of drug misuse, according to a study presented at the European Society of Emergency Medicine (EUSEM)‘s recent congress.

The study found half of patients discharged from an ED with acute pain required five tablets or fewer of morphine 5 mg or an equivalent opioid painkiller to help manage their pain and recover from their injury or condition at home.

By tailoring the number of opioid painkillers prescribed for each patient, ED clinicians can ensure the right balance between sufficient pain relief and avoiding the over-prescribing of these drugs, which can lead to dependence and abuse in some cases.

Professor Raoul Daoust, from the University of Montreal, Canada, who presented the research, said: ‘Opioids such as morphine can be very beneficial for patients suffering acute pain, for example when they have injured their neck or broken a bone. However, patients are often prescribed too many opioid tablets and that means unused tablets are available for misuse. On the other hand, since the opioid crisis, the tendency in the USA is to not prescribe opioids at all, leaving some patient in agonising pain.

‘With this research I wanted to provide a tailored approach to prescribing opioids so that patients have enough to manage their pain but almost no unused tablets available for misuse.‘

Acute pain recovery at home

Some 2,240 adult patients were recruited for the study, all of whom were treated at one of six hospital EDs in Canada for a condition that causes acute pain. They were each discharged with an opioid prescription and were asked to complete a pain medication diary for the following two weeks.

While half of patients took five 5 mg morphine tablets or fewer, the researchers noted that the number of tablets each patient required during the two-week period varied greatly according to the patient’s painful condition. For example, patients suffering from renal colic or abdominal pain needed only eight tablets and patient with broken bones needed 24 tablets.

Professor Daoust added: ‘Our findings make it possible to adapt the quantity of opioids we prescribe according to patient need. We could ask the pharmacist to also provide opioids in small portions, such as five tablets initially, because for half of patients that would be enough to last them for two weeks.’

Also commenting on the results, Professor Youri Yordanov from the St Antoine Hospital emergency department in Paris, France, who is chair of the EUSEM 2023 abstract committee but was not involved in the research, added: ‘It’s estimated that millions of people around the world are struggling with opioid addiction and more than 100,000 people die of opioid overdose every year. These drugs play an important role in emergency medicine, but we need to ensure they are prescribed wisely.

‘This study shows how opioid prescriptions could be adapted to specific acute pain conditions, and how they could be dispensed in relatively small numbers at the pharmacy to lower the chance of misuse. This research could provide a safer way to prescribe opioids that could be applied in emergency departments anywhere in the world.‘

Although widely prescribed in an emergency setting, a recent study has found that using opioids for patients with acute low back or neck pain offers no significant pain relief advantage compared to placebo.

IV paracetamol provides similar level of analgesia to NSAIDs and opiates for acute pain in ED

18th May 2023

IV paracetamol provides similar analgesic relief to other treatments used for acute pain in emergency care, but might not be the best first-line drug, a new study has found.

Use of intravenous (IV) paracetamol for patients presenting at an emergency department (ED) with acute pain, irrespective of the aetiology, provides a similar level of analgesia after 30 minutes as both IV NSAIDs or opiates. However, NSAIDs require less rescue analgesia than paracetamol, suggesting that in the absence of contra-indications, the former would be a better first-line choice. This is according to the findings of a meta-analysis by Qatarian researchers.

Pain is a common presenting complaint within an ED. For instance, a review of 1,665 visits to ED found that in 61.2% of cases, pain was documented somewhere on the chart. IV paracetamol is a commonly used analgesic, with some, albeit limited evidence of efficacy according to a review of 14 studies. Nevertheless, many of the studies included in the review had several methodological flaws, hence lowering the certainty of the findings.

Given these flaws, the researchers undertook the current study to update the earlier review, particularly as over 20 studies had been published since the original review in 2016. The team examined the comparative analgesia provided by IV paracetamol, NSAIDs (intravenous or intramuscular) or IV opioids all used alone, in adults attending an ED with acute pain due to various causes.

The primary outcome was the mean difference (MD) in pain reduction for each group (i.e. IV paracetamol, NSAIDs or opiates), 30 minutes (T30) post-dose. Secondary outcomes were the MD in pain reduction after 60 (T60), 90 (T90) and 120 (T120) minutes. The team also considered the need for rescue medication at the different time points for the three treatment interventions.

Analgesic effect of IV paracetamol

The review identified 27 trials with 5,427 patients and of which, 25 trials had data for use in the meta-analysis.

There was no significant difference in the mean pain reduction at T30 between IV paracetamol and opiates (MD = −0.13, 95% CI −1.49 to 1.22). Similarly, the difference between paracetamol and NSAIDs was also non-significant (MD = −0.27, 95% CI −1.0 to 1.54). However, while there were no important analgesic differences between the treatments, the researchers did identify significant heterogeneity across trials for all comparisons (p < 0.001 in all cases).

Despite the similar analgesic effects, the need for rescue analgesia at T30 was higher in the paracetamol compared to NSAID group (risk ratio, RR = 1.50, 95% CI 1.23 – 1.83) but not for paracetamol and opiates (RR = 1.07, 95% CI 0.67 – 1.70). Furthermore, adverse effects were 50% lower with paracetamol in comparison to opiates (RR = 0.50, 95% CI 0.40 – 0.62) but not different compared to NSAIDs (RR = 1.30, 95% CI 0.78 – 2.15).

At T60, T90 and T120, there was no difference between paracetamol and opiates though paracetamol was inferior to NSAIDs at T60.

These findings led the authors to conclude that while reductions in pain from IV paracetamol after 30 minutes were similar to the other two drug classes, since NSAID use was associated with a lower need for rescue analgesia, these drugs should be considered as a first-line treatment option unless there are contra-indications.

IV paracetamol clinically equivalent to hydromorphone for acute pain relief in older adults at ED

15th September 2022

IV paracetamol provides non-inferior clinical pain relief to hydromorphone for older adults with acute pain seen at an emergency department

Use of intravenous (IV) paracetamol (acetaminophen) offers clinically equivalent pain relief to IV hydromorphone in older patients presenting at an emergency department (ED) with acute pain that would warrant the use of opiates, according to the findings of a randomised trial by researchers from the Department of Emergency Medicine, Albert Einstein College of Medicine, New York, US.

Older adults frequently present to an ED with pain, which is often both under recognised and under treated. In fact, effective pain management among older adults is a challenge since this group are at an increased risk for adverse events associated with systemic analgesics.

Moreover, there is some data to suggest that older adults are less likely to receive pain medication. In a study of 7,585 pain-related ED visits by patients aged 75 years or older, such individuals were less likely than visits by patients aged 35 to 54 years to result in administration of an analgesic (49% versus 68.3%) or an opioid (34.8% versus 49.3%). IV hydromorphone is an opioid used in the management of acute pain though its efficacy is similar to IV morphine in older adults.

In addition, IV paracetamol has been shown to be an effective analgesic among older adults after major orthopaedic surgery. Nevertheless, whether IV paracetamol could provide a similar level of analgesia for older adults presenting at an ED with acute pain, where an opiate would normally be considered, is uncertain.

For the present study, the US team undertook a randomised trial that compared IV paracetamol with IV hydromorphone in older adults with acute pain that was deemed sufficient to warrant the use of IV opioids. Participants were aged 65 years and older and randomised to receive 1,000 mg of IV paracetamol or 0.5 mg of intravenous hydromorphone.

Pain was assessed using a verbal 0 to 10 scale with 0 equating with no pain and 10, the worst pain imaginable and which was assessed at baseline and after 15, 30, 45, 60, 90 and 180 minutes. Any adverse effects were assessed using open ended questions.

The primary outcome was the improvement in pain score from baseline after 60 minutes. For the secondary outcome, the researchers looked at the need to use of additional medication for pain relief.

Researchers also documented the proportion of patients achieving the minimum clinically important improvement in pain, defined as a 1.3 point change on the pain relief scale.

IV paracetamol and change in pain relief

A total of 162 participants with a mean age of 74.5 years (53.5% female) were equally randomised between the two therapies. The median baseline pain score was 10 in both groups.

After 60 minutes, patients receiving IV paracetamol had a mean improvement in pain score of 3.6 units whereas those with IV hydromorphone had a mean improvement of 4.6 units (95% CI for the difference was 0.1 – 2).

In addition, a similar proportion (77% vs 78%) of patients receiving paracetamol and hydromorphone respectively, achieved the minimum clinically important improvement (1.3) after 60 minutes. However, a higher proportion of patients receiving paracetamol required additional pain relief medication compared to hydromorphone (46% vs 38%).

Overall adverse effects were similar between the two groups. Finally, after 60 minutes, only 37% of those given paracetamol and 53% hydromorphone, saw a > 50% improvement in pain relief.

The authors concluded that although hydromorphone provided statistically superior pain relief to paracetamol, this difference was not clinically important although they cautioned that these findings may not generalise well outside of the population studied.

Citation
Kolli S et al. A Randomized Study of Intravenous Hydromorphone Versus Intravenous Acetaminophen for Older Adult Patients with Acute Severe Pain Ann Emerg Med 2022