Despite concerns about the overuse of opioids in the United States, analgesics containing opioids remain the first-line treatment for moderate-to-severe acute pain among patients presenting to the ED. Acute extremity pain is a common presenting condition in the ED, and many analgesic options are available to manage it. However, few studies have compared the effects of these various treatments. A randomized, double-blind clinical trial was conducted to compare the degree of pain relief achieved among ED patients with acute extremity pain who received one of four combination analgesics. All treatments included acetaminophen, and only one did not contain an opioid.

A total of 416 patients ages 21 to 64 years who presented to the ED with acute extremity pain and had a clinical indication for radiologic imaging were enrolled in the study. They were randomized to receive a single dose of an oral combination analgesic: ibuprofen 400 mg plus acetaminophen 1,000 mg; oxycodone 5 mg plus acetaminophen 325 mg; hydrocodone 5 mg plus acetaminophen 300 mg; or codeine 30 mg plus acetaminophen 300 mg.

One and two hours after taking the medication, patients rated their pain intensity on a numerical rating scale from 0 to 10. Pain intensity decreased over time in all treatment groups. At two hours, the mean pain score rating decreased by 4.3 in the ibuprofen plus acetaminophen group, by 4.4 in the oxycodone plus acetaminophen group, by 3.5 in the hydrocodone plus acetaminophen group, and by 3.9 in the codeine plus acetaminophen group. None of the between-group differences was statistically significant or met the definition of a minimally clinically important difference (1.3) in the mean pain score.

The authors suggest that a combination of ibuprofen and acetaminophen represents an alternative to oral opioid use in the management of acute extremity pain. They conclude that this change in prescribing practices could reduce the number of people exposed to opioids and thus the risk of addiction.

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