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Comparative Effectiveness of Analgesics To Reduce Acute Pain in the Prehospital Setting

Comparative Effectiveness Review, No. 220

Investigators: , Pharm.D., , Pharm.D., , Pharm.D., , Pharm.D., , M.D., Ph.D., , Pharm.D., , M.D., and , M.D.

Author Information
Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 19-EHC021-EF

Structured Abstract

Objective:

To assess comparative effectiveness and harms of opioid and nonopioid analgesics administered by emergency medical services for treatment of moderate to severe acute pain in the prehospital setting.

Data sources:

MEDLINE®, Embase®, and Cochrane Central from earliest date through May 9, 2019; hand searches of references of relevant studies and study registries.

Review methods:

Two investigators screened abstracts, reviewed full-text files, abstracted data, and assessed study-level risk of bias. We performed meta-analyses when appropriate and graded the strength of evidence (SOE) upon which conclusions were made for a priori determined comparisons and outcomes. We defined the following as clinically important differences: 2 points on a 0 to 10 pain scale; time to analgesia of 5 minutes; 10-percent absolute risk difference for any adverse event; and 5-percent absolute risk difference for hypotension, respiratory depression, and mental status changes.

Results:

We included 52 randomized controlled trials and 13 observational studies. Due to the absence or insufficiency of prehospital evidence we based conclusions for initial analgesia on indirect evidence from the emergency department setting. As initial analgesics, we found no evidence of a clinically important difference in the change of pain scores with opioids versus ketamine administered primarily intravenously (IV) (low SOE), IV acetaminophen (APAP) (low SOE), or nonsteroidal anti-inflammatory drugs (NSAIDs) administered primarily IV (moderate SOE). The combined use of an opioid and ketamine, administered primarily IV, may reduce pain more than an opioid alone at 15 and 30 minutes (low SOE), but we found no evidence of a clinically important difference at 60 minutes (low SOE). We found no evidence of a clinically important difference in time to analgesia with opioids compared with APAP, both administered IV. Opioids may cause fewer adverse events than ketamine (low SOE), primarily administered intranasally. Opioids cause less dizziness than ketamine (low SOE) but may increase the risk of respiratory depression compared with ketamine (low SOE), primarily administered IV. Opioids cause more dizziness (moderate SOE) and may cause more adverse events than APAP (low SOE), both administered IV, but we found no evidence of a clinically important difference in hypotension (low SOE). Opioids may cause more adverse events and more drowsiness than NSAIDs (low SOE), administered primarily IV. Evidence on comparative effects of nitrous oxide and on harms of combined opioid and ketamine is insufficient.

For patients whose pain is not adequately reduced by IV morphine initially, we found that giving IV ketamine may reduce pain more and may be quicker than giving additional IV morphine (low SOE, insufficient evidence to determine comparative harms).

Conclusion:

As initial analgesia administered primarily IV, opioids are no different than ketamine, APAP, and NSAIDs in reducing acute pain in the prehospital setting. Opioids may cause fewer total side effects than ketamine, but more than APAP or NSAIDs. Differences in specific side effects vary between analgesics and can further inform treatment decisions. Combined administration of an opioid and ketamine may reduce acute pain more than an opioid alone, but comparative harms are uncertain. When initial morphine is inadequate in reducing pain, giving ketamine may provide greater and quicker acute pain relief than giving additional morphine, although comparative harms are uncertain. Due to indirectness, SOE is generally low, and future research in the prehospital setting is needed.

Contents

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 5600 Fishers Lane, Rockville, MD 20857; www.ahrq.gov Contract No. 290-20-1500012-I Prepared by: University of Connecticut Evidence-based Practice Center, Storrs, CT

Suggested citation:

Sobieraj DM, Baker WL, Martinez BK, Miao B, Hernandez AV, Coleman CI, Cicero MX, Kamin RA. Comparative Effectiveness of Analgesics To Reduce Acute Pain in the Prehospital Setting. Comparative Effectiveness Review No. 220. (Prepared by the University of Connecticut Evidence-based Practice Center under Contract No. 290-2015-00012-I.) AHRQ Publication No. 19-EHC021-EF. Rockville, MD: Agency for Healthcare Research and Quality; August 2019. Posted final reports are located on the Effective Health Care Program search page. DOI: https://doi.org/10.23970/AHRQEPCCER220.

This report is based on research conducted by the University of Connecticut Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2015-00012-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.

The information in this report is intended to help healthcare decision makers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of healthcare services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.

This report is made available to the public under the terms of a licensing agreement between the author and the Agency for Healthcare Research and Quality. This report may be used and reprinted without permission except those copyrighted materials that are clearly noted in the report. Further reproduction of those copyrighted materials is prohibited without the express permission of copyright holders.

AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.

This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program website at www.effectivehealthcare.ahrq.gov. Search on the title of the report.

People using assistive technology may not be able to fully access information in this report. For assistance contact vog.shh.qrha@CPE.

Bookshelf ID: NBK546202PMID: 31509367

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