SOURCE: Chang AK, Bijur PE, Esses D, et al. Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: A randomized clinical trial. JAMA 2017;318:1661-1667.

The desire to provide meaningful pain relief for patients with acute severe pain is complicated by concerns about potential overuse of opioids, sometimes leading to misuse, diversion, dependency, and addiction. Despite the commonplace nature of acute pain syndromes (e.g., acute fracture), the literature base comparing different analgesic strategies is modest.

Chang et al performed a randomized, controlled trial among adults (n = 411) presenting with severe acute pain to EDs in the Bronx. The authors compared four different pain regimens, with the specific outcome of change in pain at two hours post-analgesic as measured on a 10-point (0-10) numeric pain rating scale. At baseline, the mean pain scale score was 8.7, indicative of moderately severe to severe pain.

The four regimens (each given as a single dose) were ibuprofen 400 mg/acetaminophen 1,000 mg, oxycodone 325 mg/acetaminophen 325 mg, hydrocodone 5 mg/acetaminophen 300 mg, and codeine 30 mg/acetaminophen 300 mg. At two hours, there was no statistically significant difference in pain reduction between the four different treatment arms. The success of a non-opioid treatment arm in direct comparison with three opioid treatment arms should justify greater consideration of non-opioid treatment for acute severe pain.