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Chen Q, Maher CG, Han CS, Abdel Shaheed C, Lin CWC, Rogan EM, Machado GC. Continued Opioid Use and Adverse Events Following Provision of Opioids for Musculoskeletal Pain in the Emergency Department: A Systematic Review and Meta-Analysis. Drugs 2023; 83:1523-1535. [PMID: 37768540 PMCID: PMC10624756 DOI: 10.1007/s40265-023-01941-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND The prevalence of continued opioid use or serious adverse events (SAEs) following opioid therapy in the emergency department (ED) for musculoskeletal pain is unclear. The aim of this review was to examine the prevalence of continued opioid use and serious adverse events (SAEs) following the provision of opioids for musculoskeletal pain in the emergency department (ED) or at discharge. METHODS Records were searched from MEDLINE, EMBASE and CINAHL from inception to 7 October 2022. We included randomised controlled trials and observational studies enrolling adult patients with musculoskeletal pain who were administered and/or prescribed opioids in the ED. Continued opioid use and opioid misuse data after day 4 since ED discharge were extracted. Adverse events were coded using the Common Terminology Criteria for Adverse Events (CTCAE), and those rated as grades 3-4 (severe or life-threatening) and grade 5 (death) were considered SAEs. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. RESULTS Seventy-two studies were included. Among opioid-naïve patients who received an opioid prescription, 6.8-7.0% reported recent opioid use at 3-12 months after discharge, 4.4% filled ≥ 5 opioid prescriptions and 3.1% filled > 90-day supply of opioids within 6 months. The prevalence of SAEs was 0.02% [95% confidence interval (CI) 0, 0.2%] in the ED and 0.1% (95% CI 0, 1.5%) within 2 days. One study observed 42.9% of patients misused opioids within 30 days after discharge. CONCLUSIONS Around 7% of opioid-naïve patients with musculoskeletal pain receiving opioid therapy continue opioid use at 3-12 months after ED discharge. SAEs following ED administration of an opioid were uncommon; however, studies only monitored patients for 2 days. PROTOCOL REGISTRATION 10.31219/osf.io/w4z3u.
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Affiliation(s)
- Qiuzhe Chen
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia.
| | - Chris G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| | - Christopher S Han
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| | - Eileen M Rogan
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
- Emergency Department, Canterbury Hospital, Campsie, NSW, Australia
| | - Gustavo C Machado
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
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Jones CMP, Lin CWC, Jamshidi M, Abdel Shaheed C, Maher CG, Harris IA, Patanwala AE, Dinh M, Mathieson S. Effectiveness of Opioid Analgesic Medicines Prescribed in or at Discharge From Emergency Departments for Musculoskeletal Pain : A Systematic Review and Meta-analysis. Ann Intern Med 2022; 175:1572-1581. [PMID: 36252245 DOI: 10.7326/m22-2162] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The comparative benefits and harms of opioids for musculoskeletal pain in the emergency department (ED) are uncertain. PURPOSE To evaluate the comparative effectiveness and harms of opioids for musculoskeletal pain in the ED setting. DATA SOURCES Electronic databases and registries from inception to 7 February 2022. STUDY SELECTION Randomized 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. DATA EXTRACTION Pain and disability were rated on a scale of 0 to 100 and pooled using a random-effects model. Certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. DATA SYNTHESIS Forty-two articles were included (n = 6128). In the ED, opioids were statistically but not clinically more effective in reducing pain in the short term (about 2 hours) 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 anesthetics. LIMITATIONS Low or very low GRADE ratings for some outcomes, unexplained heterogeneity, and little information on long-term outcomes. CONCLUSION The risk-benefit balance of opioids versus placebo, paracetamol, NSAIDs, and local or systemic anesthetics 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. PRIMARY FUNDING SOURCE None. (PROSPERO: CRD42021275293).
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Affiliation(s)
- Caitlin M P Jones
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Masoud Jamshidi
- Department of Sports Physiology, University of Tehran, Tehran, Iran (M.J.)
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Ian A Harris
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW Sydney, Sydney, New South Wales, Australia (I.A.H.)
| | - Asad E Patanwala
- Royal Prince Alfred Hospital, and School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia (A.E.P.)
| | - Michael Dinh
- Sydney Local Health District and The University of Sydney, Sydney, New South Wales, Australia (M.D.)
| | - Stephanie Mathieson
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
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van der Gaag WH, Roelofs PDDM, Enthoven WTM, van Tulder MW, Koes BW. Non-steroidal anti-inflammatory drugs for acute low back pain. Cochrane Database Syst Rev 2020; 4:CD013581. [PMID: 32297973 PMCID: PMC7161726 DOI: 10.1002/14651858.cd013581] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute low back pain (LBP) is a common health problem. Non-steroidal anti-inflammatory drugs (NSAIDs) are often used in the treatment of LBP, particularly in people with acute LBP. In 2008, a Cochrane Review was published about the efficacy of NSAIDs for LBP (acute, chronic, and sciatica), identifying a small but significant effect in favour of NSAIDs compared to placebo for short-term pain reduction and global improvement in participants with acute LBP. This is an update of the previous review, focusing on acute LBP. OBJECTIVES To assess the effects of NSAIDs compared to placebo and other comparison treatments for acute LBP. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, PubMed, and two trials registers for randomised controlled trials (RCT) to 7 January 2020. We also screened the reference lists from relevant reviews and included studies. SELECTION CRITERIA We included RCTs that assessed the use of one or more types of NSAIDs compared to placebo (the main comparison) or alternative treatments for acute LBP in adults (≥ 18 years); conducted in both primary and secondary care settings. We assessed the effects of treatment on pain reduction, disability, global improvement, adverse events, and return to work. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials to be included in this review, evaluated the risk of bias, and extracted the data. If appropriate, we performed a meta-analysis, using a random-effects model throughout, due to expected variability between studies. We assessed the quality of the evidence using the GRADE approach. We used standard methodological procedures recommended by Cochrane. MAIN RESULTS We included 32 trials, with a total of 5356 participants (age range 16 to 78 years). Follow-up ranged from one day to six months. Studies were conducted across the globe, the majority taking place in Europe and North-America. Africa and the Eastern Mediterranean region were not represented. We considered seven studies at low risk of bias. Performance and attrition were the most common biases. There was often a lack of information on randomisation procedures and allocation concealment (selection bias); studies were prone to selective reporting bias, since most studies did not register their trials. Almost half of the studies were industry-funded. There is moderate quality evidence that NSAIDs are slightly more effective in short-term (≤ 3 weeks) reduction of pain intensity (visual analogue scale (VAS), 0 to 100) than placebo (mean difference (MD) -7.29 (95% confidence interval (CI) -10.98 to -3.61; 4 RCTs, N = 815). There is high quality evidence that NSAIDs are slightly more effective for short-term improvement in disability (Roland Morris Disability Questionnaire (RMDQ), 0 to 24) than placebo (MD -2.02, 95% CI -2.89 to -1.15; 2 RCTs, N = 471). The magnitude of these effects is small and probably not clinically relevant. There is low quality evidence that NSAIDs are slightly more effective for short-term global improvement than placebo (risk ratio (RR) 1.40, 95% CI 1.12 to 1.75; 5 RCTs, N = 1201), but there was substantial heterogeneity (I² 52%) between studies. There is very low quality evidence of no clear difference in the proportion of participants experiencing adverse events when using NSAIDs compared to placebo (RR 0.86, 95% CI 0.63 to 1.18; 6 RCTs, N = 1394). There is very low quality evidence of no clear difference between the proportion of participants who could return to work after seven days between those who used NSAIDs and those who used placebo (RR 1.48, 95% CI 0.98 to 2.23; 1 RCT, N = 266). There is low quality evidence of no clear difference in short-term reduction of pain intensity between those who took selective COX-2 inhibitor NSAIDs compared to non-selective NSAIDs (mean change from baseline -2.60, 95% CI -9.23 to 4.03; 2 RCTs, N = 437). There is moderate quality evidence of conflicting results for short-term disability improvement between groups (2 RCTs, N = 437). Low quality evidence from one trial (N = 333) reported no clear difference between groups in the proportion of participants experiencing global improvement. There is very low quality evidence of no clear difference in the proportion of participants experiencing adverse events between those who took COX-2 inhibitors and non-selective NSAIDs (RR 0.97, 95% CI 0.63 to 1.50; 2 RCTs, N = 444). No data were reported for return to work. AUTHORS' CONCLUSIONS This updated Cochrane Review included 32 trials to evaluate the efficacy of NSAIDs in people with acute LBP. The quality of the evidence ranged from high to very low, thus further research is (very) likely to have an important impact on our confidence in the estimates of effect, and may change the estimates. NSAIDs seemed slightly more effective than placebo for short-term pain reduction (moderate certainty), disability (high certainty), and global improvement (low certainty), but the magnitude of the effects is small and probably not clinically relevant. There was no clear difference in short-term pain reduction (low certainty) when comparing selective COX-2 inhibitors to non-selective NSAIDs. We found very low evidence of no clear difference in the proportion of participants experiencing adverse events in both the comparison of NSAIDs versus placebo and selective COX-2 inhibitors versus non-selective NSAIDs. We were unable to draw conclusions about adverse events and the safety of NSAIDs for longer-term use, since we only included RCTs with a primary focus on short-term use of NSAIDs and a short follow-up. These are not optimal for answering questions about longer-term or rare adverse events.
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Affiliation(s)
| | - Pepijn DDM Roelofs
- University Medical Center Groningen, University of GroningenDepartment of Health Sciences, Community and Occupational MedicineGroningenNetherlands
- Rotterdam University of Applied SciencesResearch Centre Innovations in CareRotterdamNetherlands
| | - Wendy TM Enthoven
- Erasmus Medical CenterDepartment of General PracticeRotterdamNetherlands
| | - Maurits W van Tulder
- VU University AmsterdamDepartment of Health Sciences, Faculty of Earth and Life SciencesPO Box 7057Room U454AmsterdamNetherlands1007 MB
- Aarhus University HospitalDepartment of Physiotherapy & Occupational TherapyAarhusDenmark
| | - Bart W Koes
- Erasmus Medical CenterDepartment of General PracticeRotterdamNetherlands
- University of Southern DenmarkCenter for Muscle and HealthOdenseDenmark
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Saragiotto BT, Machado GC, Ferreira ML, Pinheiro MB, Abdel Shaheed C, Maher CG. Paracetamol for low back pain. Cochrane Database Syst Rev 2016; 2016:CD012230. [PMID: 27271789 PMCID: PMC6353046 DOI: 10.1002/14651858.cd012230] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Analgesic medication is the most frequently prescribed treatment for low back pain (LBP), of which paracetamol (acetaminophen) is recommended as the first choice medication. However, there is uncertainty about the efficacy of paracetamol for LBP. OBJECTIVES To investigate the efficacy and safety of paracetamol for non-specific LBP. SEARCH METHODS We conducted searches on the Cochrane Central Register of Controlled Trials (CENTRAL, which includes the Back and Neck Review Group trials register), MEDLINE, EMBASE, CINAHL, AMED, Web of Science, LILACS, and IPA from their inception to 7 August 2015. We also searched the reference lists of eligible papers and trial registry websites (WHO ICTRP and ClinicalTrials.gov). SELECTION CRITERIA We only considered randomised trials comparing the efficacy of paracetamol with placebo for non-specific LBP. The primary outcomes were pain and disability. We also investigated quality of life, function, adverse effects, global impression of recovery, sleep quality, patient adherence, and use of rescue medication as secondary outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently performed the data extraction and assessed risk of bias in the included studies. We also evaluated the quality of evidence using the GRADE approach. We converted scales for pain intensity to a common 0 to 100 scale. We quantified treatment effects using mean difference for continuous outcomes and risk ratios for dichotomous outcomes. We used effect sizes and 95% confidence intervals as a measure of treatment effect for the primary outcomes. When the treatment effects were smaller than 9 points on a 0 to 100 scale, we considered the effect as small and not clinically important. MAIN RESULTS Our searches retrieved 4449 records, of which three trials were included in the review (n = 1825 participants), and two trials were included in the meta-analysis. For acute LBP, there is high-quality evidence for no difference between paracetamol (4 g per day) and placebo at 1 week (immediate term), 2 weeks, 4 weeks, and 12 weeks (short term) for the primary outcomes. There is high-quality evidence that paracetamol has no effect on quality of life, function, global impression of recovery, and sleep quality for all included time periods. There were also no significant differences between paracetamol and placebo for adverse events, patient adherence, or use of rescue medication. For chronic LBP, there is very low-quality evidence (based on a trial that has been retracted) for no effect of paracetamol (1 g single intravenous dose) on immediate pain reduction. Finally, no trials were identified evaluating patients with subacute LBP. AUTHORS' CONCLUSIONS We found that paracetamol does not produce better outcomes than placebo for people with acute LBP, and it is uncertain if it has any effect on chronic LBP.
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Affiliation(s)
- Bruno T Saragiotto
- Universidade Cidade de São PauloMasters and Doctoral Programs in Physical TherapySao PauloBrazil
| | - Gustavo C Machado
- Sydney Medical School, The University of SydneySydney School of Public HealthPO Box M179, Missenden RdSydneyNSWAustralia2050
| | - Manuela L Ferreira
- Sydney Medical School, The University of SydneyInstitute of Bone and Joint Research, The Kolling InstituteSydneyNSWAustralia
| | - Marina B Pinheiro
- The University of SydneyDiscipline of Physiotherapy, Faculty of Health SciencesRoom S227, S BlockSydneyAustraliaNSW 2141
| | | | - Christopher G Maher
- University of SydneySydney School of Public HealthLevel 10 North, King George V Building, Missenden Road, CamperdownSydneyNSWAustralia2050
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Li TY, Li YK, Chan CM. Who are Prone to Develop Adverse Effects with Oral Tramadol? a Retrospective Cohort Study. HONG KONG J EMERG ME 2014. [DOI: 10.1177/102490791402100101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective Oral tramadol is a commonly prescribed analgesic in Hong Kong. Significant adverse effects are frequently observed in our locality. Our study aims to describe the rate of significant adverse effect that warrant discontinuation of oral tramadol and identify the risk factors for development of adverse effect. Design Retrospective cohort study. Methods Adult patients aged greater than 18 years old admitted to the emergency medicine ward of a large-scale local hospital in Hong Kong being prescribed with oral tramadol during in-hospital stay were recruited. Significant adverse effects during the hospital stay were observed as the outcome of interest. Results A total of 575 subjects were recruited. 29.9% experienced significant adverse effects likely related to tramadol. Age (p=0.006; odds ratio [OR] = 1.017, 95% confidence interval [CI] = 1.005-1.029) and sex (p=0.006; OR=1.696, 95% CI= 1.166-2.465) were statistically significant predictors of adverse effects after oral tramadol. Conclusion Our study suggests that female and increasing age patients are significant predictors for the development of adverse effect after taking oral tramadol. Possible adverse effects should be explained to the patients careful especially the higher risk groups. (Hong Kong j. emerg.med. 2014;21:3-9)
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Affiliation(s)
| | - YK Li
- Princess Margaret Hospital, Accident and Emergency Department, 2-10 Princess Margaret Hospital Road, Kwai Chung, N.T., Hong Kong
| | - CM Chan
- Princess Margaret Hospital, Accident and Emergency Department, 2-10 Princess Margaret Hospital Road, Kwai Chung, N.T., Hong Kong
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Gopalraju P, Lalitha RM, Prasad K, Ranganath K. Comparative study of intravenous Tramadol versus Ketorolac for preventing postoperative pain after third molar surgery--a prospective randomized study. J Craniomaxillofac Surg 2013; 42:629-33. [PMID: 24269645 DOI: 10.1016/j.jcms.2013.09.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 08/30/2013] [Accepted: 09/13/2013] [Indexed: 11/29/2022] Open
Abstract
The aim of this comparative, prospective, randomized, controlled study was to evaluate two different regimens of analgesics: a preoperative intravenous dose of either Tramadol or Ketorolac given 10 min prior to surgery to assess their impact on clinical recovery after third molar surgery. Forty patients requiring surgical extraction of unilateral impacted mandibular third molars similar in position were enrolled in the study. Patients were randomly divided into two groups based on permuting the numbers. Patients in Group 1 and Group 2 were administered either Tramadol 50 mg or Ketorolac 30 mg, intravenously, 10 min prior to surgery. The difference in postoperative pain was assessed by four primary points: pain intensity as measured by a 10 mm visual analogue scale hourly for 12 h, median time to rescue analgesics, number of analgesics consumed and patient's overall 5-point global assessment scale. Throughout the 12 h investigation period, patients treated with Ketorolac reported significantly lower pain intensity scores, significantly longer time to rescue analgesics (Acetaminophen 500 mg) and less intake of postoperative analgesics. In Group 2, 40% of the patient had good overall assessment as compared to Group 1 where only 25% of patients had good overall assessment. The current study shows that pre-emptive use of Inj. Ketorolac 30 mg intravenously can reduce the severity of the postoperative sequelae of asymptomatic impacted mandibular third molar surgery.
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Affiliation(s)
- Prathibha Gopalraju
- Department of Oral and Maxillofacial Surgery, M.S. Ramaiah Dental College and Hospital, New BEL Road, MSR Nagar, MSRIT Post, Bangalore 560 054, India.
| | - Ramanujapuram Manikarnike Lalitha
- Department of Oral and Maxillofacial Surgery, M.S. Ramaiah Dental College and Hospital, New BEL Road, MSR Nagar, MSRIT Post, Bangalore 560 054, India
| | - Kavitha Prasad
- Department of Oral and Maxillofacial Surgery, M.S. Ramaiah Dental College and Hospital, New BEL Road, MSR Nagar, MSRIT Post, Bangalore 560 054, India
| | - Krishnappa Ranganath
- Department of Oral and Maxillofacial Surgery, M.S. Ramaiah Dental College and Hospital, New BEL Road, MSR Nagar, MSRIT Post, Bangalore 560 054, India
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