A combination of two over-the-counter pain medications — ibuprofen and acetaminophen — is just as effective as prescription opioids at reducing the acute pain of a sprained or broken arm or leg, according a study published this week in the Journal of the American Medical Association (JAMA).
The findings support what many people have been saying for a long time: that opioid pain medications are overprescribed.
We are, of course, in the midst of an opioid overdose epidemic. Since 2000, almost 500,000 Americans have died of opioid overdoses. Many of those people got addicted to the drugs after visiting a hospital emergency department — say, for an arm or leg injury suffered in a fall or while playing sports — and then leaving with a prescription for an opioid.
Indeed, almost one in three adult patients who seek care at U.S. hospital emergency departments takes home a prescription for an opioid painkiller — whether the visit was related to pain or not.
That practice is rife with danger, even for people who are given less than a month’s supply of the drugs. A study published earlier this year found that, for some individuals, receiving even a few days supply of opioids for acute pain can lead to long-term dependency.
It found, for example, that one in five people given a 10-day supply of opioid painkillers became long-term users.
A ‘gold standard’ design
For the current study, a team of researchers led by Dr. Andrew Chang of Albany Medical College, conducted a randomized controlled clinical trial, which is considered the “gold standard” of medical research.
The study involved 411 patients (aged 21 to 64) who had sought medical care at two urban emergency departments after having sprained, strained or broken an arm or leg. (About 20 percent of the patients had a fracture.)
The patients were randomly assigned to one of four groups. One group received a pill for their acute pain that contained a combination of ibuprofen and acetaminophen, the ingredients in Advil and Tylenol. The other groups were given a pill for their pain that contained a prescription opioid as well as acetaminophen, either oxycodone and acetaminophen (Percocet), hydrocodone and acetaminophen (Vicodin), or codeine and acetaminophen (Tylenol No. 3).
All the patients were asked to rate their pain immediately before taking the pain medication and again both one and two hours afterward (before they left the emergency department). The assessments were done using an 11-point scale (0 = no pain; 10 = worst possible pain).
The study found that the intensity of pain was similar among all four groups before they took the medication, with a mean score of 8.7 on the scale. The pain then declined over time in all four groups — and by similar levels: 4.3 points in the ibuprofen/acetaminophen group, 4.4 points in the oxycodone/acetaminophen group, 3.5 in the hydrocodone/acetaminophen group and 3.9 in the codeine/acetaminophen group.
Those differences were not statistically significant, Change and his colleagues stress.
Limitations and implications
The major limitation of the study is that it had the patients assess their pain only while they were in the emergency department. The study did not look at how the ibuprofen/acetaminophen combination would work in comparison to opioids once the patients went home.
Also, the participants had a specific type of acute pain — from sprained or broken arms and legs.
But the findings of this study — which, remarkably, is one of only a few that has examined in a real-world setting whether non-opioid medications can be as effective as opioids at reducing pain — are promising.
“Preventing new patients from becoming addicted to opioids may have a greater effect on the opioid epidemic than providing sustained treatment to patients already addicted to opioids, in whom it may take many years to achieve recovery,” writes Dr. Demetrio Kyriacou, a senior editor at JAMA and a professor of emergency medicine at Northwestern University, in an accompanying editorial.
Yet, as Kyriacou also acknowledges, “[s]temming the opioid addiction crisis will … require reexamination of the long-standing assumptions that opioids are superior to nonopioids in most clinical situations requiring management of moderate to severe pain.”
Meanwhile, while we’re waiting for that reexamination, more than 33,000 people in the United States will die of opioid overdoses this year.
FMI: You’ll find an abstract of the study on the JAMA website, but the full study is behind a paywall.