Effectiveness of Opioid Analgesic Medicines Prescribed in or at Discharge From Emergency Departments for Musculoskeletal Pain: A Systematic Review and Meta-analysis

Thank you to APS member Stephanie Mathieson and her colleagues Caitlin Jones, Christine Lin, Masoud Jamshidi, Christina Abdel Shaheed, Christopher Maher, Ian Harris, Asad Patanwala, and Michael Dinh for sharing the following recent publication.

Article first published online: 18 October 2022

Journal Reference: Annals of Internal Medicine

DOI: 10.7326/M22-2162

Abstract

Background

The comparative benefits and harms of opioids for musculoskeletal pain in the emergency department (ED) are uncertain. This review aimed to evaluate the comparative effectiveness and harms of opioids for musculoskeletal pain in the ED setting.

Design

Systematic review and meta-analysis (PROSPERO: CRD42021275293)

Methods

Electronic databases and registries from inception to 7 February 2022 were searched for randomised controlled trials of any opioid analgesic compared with placebo or a nonopioid analgesic administered or prescribed to adults in or on discharge from the ED. Pain and disability were rated on a scale of 0 to 100 and pooled using a random-effects model. For studies in the ED, the time points were ≤30 minutes, approximately 2 hours (>30 minutes to ≤4 hours), and approximately 12 hours (>4 hours). For studies where the intervention occurred upon discharge from the ED, the time points were immediate term (≤48 hours), short term (>48 hours to ≤7 days), and long term (>7 days). Risk of bias was assessed using the original Cochrane Risk of Bias tool. Certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework.

Results

Forty-two articles were included (n= 6,128). In the ED, opioids were statistically but not clinically more effective in reducing pain in the short term than placebo and paracetamol (acetaminophen) but were not clinically or statistically more effective than nonsteroidal anti-inflammatory drugs (NSAIDs) or local or systemic anesthetics. Opioids may carry higher risk for harms than placebo, paracetamol, or NSAIDs, although evidence is very uncertain. There was no evidence of difference in harms associated with local or systemic anaesthetics.

Conclusions

The risk–benefit balance of opioids versus placebo, paracetamol, NSAIDs, and local or systemic anaesthetics is uncertain. Opioids may have equivalent pain outcomes compared with NSAIDs, but evidence on comparisons of harms is very uncertain and heterogeneous. Although factors such as route of administration or dosage may explain some heterogeneity, more work is needed to identify which subgroups will have a more favorable benefit–risk balance for one analgesic over another. Longer-term pain management once dose thresholds are reached is also uncertain.

Declaration

All authors have no conflicts of interest to declare.