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Jones CMP, Lin CC, Jamshidi M, et al. 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 Nov;175(11):1572-1581. doi: 10.7326/M22-2162. Epub 2022 Oct 18. (Systematic review)
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).

Ratings
Discipline Area Score
Physician 5 / 7
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Comments from MORE raters

Physician rater

Short-term analgesia in the ED of any type is not concerning. The huge missing piece of data is the follow-up to see how many patients receiving opioids are prescribed them when they go home, and how many begin a trajectory to dependence based on ED use.

Physician rater

No matter what the findings, this is a well done SR that assembled a comprehensive picture of the research evidence on this topic. In this case, the authors' interpretations may be suspect and suggest they were trying to show that opioids are ineffective for pain. In fact, 2 hours less time to relieve pain would likely be considered very 'clinically significant' by many patients with enough pain to make them come to an ED!

Physician rater

Well-done systematic review but low-quality trials, significant heterogeneity, and no discernable conclusion. This SR does not add anything to our existing knowledge despite the authors' well-intended efforts to shed light on the matter.

Physician rater

In the 21st century opioid epidemic, the value of opioid prescribing over widely available alternatives with less potential for abuse is worthwhile. This research seems to confirm similar investigators' work reviewed by ACPJC (http://pmid.us/29459958).

Physician rater

Interesting how scant and poor the data are on this important topic. Given other data about the fairly high chance of addiction (not included in the "harms" here), makes me even more wary of using narcotics.
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