In an opioid epidemic that currently claims an average of 91 lives per day, there have been many paths to addiction. For some, it started with a fall or a sports injury, a trip to a nearby emergency room and a prescription for a narcotic pain reliever that seemed to work well in the ER.
New research underscores how tragically risky — and unnecessary — such prescribing choices have been.
In a new study of patients who showed up to an emergency department with acute pain in their shoulders, arms, hips or legs, researchers found that a cocktail of two non-addictive, over-the-counter drugs relieved pain just as well as — and maybe just a little better than — a trio of opioid pain medications widely prescribed under such circumstances.
The epidemic of opiate addiction, which has left roughly 2 million Americans addicted to narcotic painkillers, has claimed more than 183,000 lives since 1999, according to the Centers for Disease Control and Prevention.
Emergency department prescribing decisions have played a key role in fueling that crisis. One study found that between 2001 and 2010, the share of U.S. emergency department visits that resulted in a prescription for an opioid analgesic rose by nearly 50%, from 21% to 31%.
Not everyone who gets narcotic pain medication will become addicted. But a report released in July by the National Academies of Sciences, Engineering and Medicine found that, among patients prescribed opioid pain relievers, at least 8% develop "opioid use disorder," and 15% to 26% engage in problematic behaviors that suggest they have become dependent.
And a 2015 study found that, among Colorado ER patients who had never taken opioids but filled such a prescription to treat a short-term pain condition, 17% were still taking a narcotic pain reliever a year later.
The report published Tuesday in the Journal of the American Medical Assn. suggests that much of this misery could have been avoided.
The trial included 416 patients who showed up to Montefiore Medical Center's Emergency Department in the Bronx. About 20% of them were diagnosed with a bone fracture. The rest suffered injuries such as a sprained ankle, a dislocated shoulder or a banged-up knee.
Upon arrival, all of these patients were evenly assigned to one of four groups. One group got a combination ibuprofen/acetaminophen tablet, containing the medications found in Advil and Tylenol. The other groups got a drug that contained a prescription narcotic, such as Percocet (a combination of oxycodone and acetaminophen), Vicodin (hydrocodone and acetaminophen) or Tylenol No. 3 (codeine and acetaminophen).
Researchers asked patients to rate their pain upon arrival and two hours after they got their medication.
Those who scoff at the modest effects of over-the-counter pain relievers may be surprised by the results: Patients who got the acetaminophen/ibuprofen treatment reported pain relief just as substantial as did the patients who got one of the opioid painkillers.
ER patients who got the over-the-counter pain cocktail reported an average decline in pain of 4.3 points on a 10-point scale. By comparison, those who got Percocet reported an average decline of 4.4 points, those who received Vicodin reported an average decline of 3.5 points and those who took Tylenol No. 3 reported an average decline of 3.9 points.
The differences among the four pills were statistically insignificant. In other words, all the treatments performed essentially the same.
The trial suggests that many patients who were first exposed to an opioid in the ER could have treated their injury without risk of addiction. And when they went home, they could have been given instructions to take 400 mg of ibuprofen (two regular-strength pills) and 1000 mg of acetaminophen (two extra-strength tablets) at a time.
(Acetaminophen has a safe daily dosing limit of 4,000 mg for adults. For ibuprofen, the limit is 3,200 mg per day.)
Stanford pain medicine specialist Dr. David Clark said that the findings of this simple, head-to-head comparison "could shape practice really very profoundly." At the same time, Clark acknowledged that he was surprised such a trial had never been done before.
"I would have thought that people who came to an ER with pain that could be managed with just pills wouldn't be given opioids," said Clark, who was not involved in the new research. "The fact that investigators thought the question needed to be answered is sort of an indicator of how oriented we are to using opioids for pain, even when simpler and safer approaches might work just as well."
Many emergency department doctors will protest that it's been years since they blithely handed out narcotic prescriptions. That's fair: Because they have been on the front lines of treating overdoses and spotting addicted patients seeking drugs, emergency physicians belong to an especially chastened medical specialty.
But it can take years for the dangers of narcotic painkillers to reach every emergency department. And pain is, after all, a key reason that people go to an emergency room.
The authors of the new study, led by Dr. Andrew K. Chang of Albany Medical College in New York, noted that their findings are in line with mounting evidence that the combination of ibuprofen and acetaminophen — two pain relievers that work by different means — outperforms opioids in a variety of patients.
So why does the impression persist among patients and even some physicians that opioids are better medicine for acute pain?
Patients often believe that prescription medications — costlier, harder to get and quite often riskier — must be better than what's in their own medicine cabinets, said Dr. Michael L. Barnett, who studies opioid prescribing patterns at Harvard University's T.H. Chan School of Public Health and was not involved in the JAMA study.
That idea may also stem from a 1986 document drafted by the World Health Organization, Chang and his coauthors wrote. Depending on the intensity of pain, that WHO "pain ladder" recommends starting with a combination of ibuprofen and acetaminophen, and then, as necessary, escalating to such "mild opioids" as codeine en route to stronger ones, including hydrocodone and oxycodone.
The WHO document was published six years after a letter in the New England Journal of Medicine asserted that "the development of addiction is rare in medical patients with no history of addiction." Although the five-sentence letter was based on a rudimentary analysis of patients from a single hospital, it was nevertheless widely cited as evidence that narcotic painkillers were safe. To many, it is now considered a fateful moment in the run-up to the current crisis.
The upshot is that doctors need better research to guide their decisions about opiate prescribing, according to Dr. Demetrios Kyriacou, a professor of emergency medicine at the Northwestern University Feinberg School of Medicine and a senior editor at JAMA. In particular, he wrote in an editorial, physicians need "prediction models" that would help them identify patients who are at heightened risk of becoming addicted.
Currently, the best clues they have come from a recent study of more than 37,000 post-surgical patients who had never used opiates. Among these patients, those most likely to refill an opioid pain prescription 90 to 180 days after their surgery were current smokers, those who abuse alcohol or illicit drugs and patients with mood disorders, anxiety and a history of pain disorders.
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3:25 p.m.: This article has been updated with comments from Dr. David Clark of Stanford and Dr. Michael L. Barnett of Harvard.