Benefits of opioids for musculoskeletal pain in the ED still unclear
The balance of risks and benefits when it comes to treating musculoskeletal pain with opioids in the ED setting remains unclear, according to researchers.
“Managing pain in the ED setting has unique challenges and goals compared with primary care or other care settings, such as the need to achieve rapid pain control,” Caitlin M.P. Jones, BOccThy (Hons), a PhD candidate at the University of Sydney, and colleagues wrote. But, “the ED setting is the point of initiation of opioids for many people who may consequently experience opioid-related harms, such as dependence, overdose, and death.”
Jones and colleagues conducted a systematic review and meta-analysis of 42 articles to better understand the comparative harms and benefits of treating musculoskeletal pain in the ED with opioids compared with placebo, NSAIDs, paracetamol (acetaminophen) and anesthetics.
The findings, published in Annals of Internal Medicine, revealed that opioids were “statistically but not clinically more effective” than placebo (mean difference = –6.3; 95% CI, –10.5 to –2.2) and acetaminophen (mean difference = –6.7; 95% CI, –11.9 to –1.5) in providing short-term pain relief. They were no more effective than NSAIDs (mean difference = –0.1; 95% CI, –2.5 to 2.3) or systemic anesthetics (mean difference = –2.1; 95% CI, –8.5 to 4.3) and may be statistically and clinically inferior to local anesthetics (mean difference = 17.3; 95% CI, 1.5-33.1).
“The risk-benefit balance of opioids vs. placebo, paracetamol, NSAIDs, and local or systemic anesthetics is uncertain,” the researchers wrote.
Opioids were linked to more adverse events than NSAIDs, acetaminophen and placebo, the researchers noted, but “the certainty of the evidence was low or very low.”
Although “opioids may carry higher risk for harms,” they wrote, the adverse events analysis “suggest that clinicians should be cautious about replacing opioids with anesthetics, such as ketamine.”
Future research, they continued, should look into other outcomes that might interest clinicians and policymakers like hospitalization rates and potential harms. It should also work to identify the subgroups that will have a greater benefit-risk balance for one analgesic over another, they wrote, adding that “there is an urgent need for more studies on opioids prescribed in the ED and upon discharge.”