Ibuprofen plus acetaminophen is as effective as an opioid plus acetaminophen in relieving acute extremity pain, according to a new study conducted across two EDs in the Bronx, New York. Researchers studied 411 ED patients admitted with acute extremity pain (mean score, 8.7 on the 11-point numerical rating scale). A little more than 400 patients were randomized to one of four treatments: 400 mg of ibuprofen and 1,000 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. At two hours, the mean pain score decreased by 4.3 points (95% confidence interval [CI], 3.6-4.9) in the ibuprofen/acetaminophen group; by 4.4 (95% CI, 3.7-5.0) in the oxycodone/acetaminophen group; by 3.5 (95% CI, 2.9-4.2) in the hydrocodone/acetaminophen group; and by 3.9 (95% CI, 3.2-4.5) in the codeine/acetaminophen group (P = 0.053). The authors concluded that for patients presenting to the ED with acute extremity pain, there were no statistically significant or clinically important differences in pain reduction at two hours among single-dose treatment with ibuprofen and acetaminophen or three different opioid/acetaminophen combinations (JAMA 2017;318:1661-1667).

An accompanying editorial noted that opioid abuse and addiction often begins with treatment of acute pain with prescription opioid medications. Often, patients receive their first opioid prescription in an ED. This study shows that the rarely used combination of ibuprofen plus acetaminophen may be an effective pain-relieving combination that avoids initiating opioids for selected patients. Whether the combination is effective for longer-term treatment is unclear (JAMA 2017;318:1661-1667).