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3rd November 2022
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
2nd November 2022
The misuse of the illicit substances methamphetamine, cocaine, opiates and cannabis has been found to increase the risk of incident atrial fibrillation (AF) according to the findings of a longitudinal analysis by Californian researchers.
Atrial fibrillation is the most frequent cardiac arrhythmia, and it has been estimated that 6 -12 million people worldwide suffer from the condition. Moreover, the presence of the arrhythmia is also independently associated with a higher risk of all-cause mortality. While it has become well established that a higher intake of alcohol as well as smoking, increases the risk of AF, the relationship with the misuse of illicit drugs is less clear. Whereas prior work has suggested that methamphetamine abuse leads to ECG changes that pose a higher risk for ventricular arrhythmias and most notably torsades de pointes, less is known about the effect on AF. However, there is some data linking an increased risk of AF from use of both cannabis and cocaine though these findings are derived from case studies. But in contrast, one study actually identified how cannabis use was associated with a lower odds of AF.
In the present study, the US researchers sought to determine whether misuse of the illicit substances, methamphetamine, cocaine, opiates and cannabis were a predictor of incident AF. The team used several California healthcare databases, e.g., emergency department and inpatient to capture repeat visits for a given patient. They extracted demographic and co-morbidity data and excluded those with known AF and looked at cases where substance use was considered present at the first healthcare encounter. The researchers then compared the baseline and clinical characteristics of patients for each of the different drugs and examined the association with AF, adjusting for covariates known to be associated with AF.
Illicit substance misuse and incident atrial fibrillation
In a total of 23,561,884 individuals, 98,271 used methamphetamine, 48,701 cocaine, 10,032 opiates and 132,834 cannabis. From this total, 4.2% developed incident AF during the period of study from 2005 to 2015. The mean age of participants ranged from 32.3 years (cannabis) to 41.1 (cocaine) and the proportion of females from 28.3% to 55%.
After adjustment for covariates, methamphetamine use was associated with an 86% higher risk of developing incident AF (Hazard ratio, HR = 1.86, 95% CI 1.81 – 1.92). Similar and significantly elevated risks were seen for cocaine (HR = 1.61), opiates (HR = 1.74) and cannabis (HR = 1.35). Interesting, polysubstance use was also associated with a higher risk of AF compared to single drug misuse (HR = 1.63, 95% CI 1.61 – 1.66).
The authors concluded that for each of the misused substances analysed, there was a higher risk of developing incident AF after controlling for conventional AF risk factors.
Lin AL et al. Cannabis, cocaine, methamphetamine, and opiates increase the risk of incident atrial fibrillation. Eur Heart J 2022