Daoust Raoul, Paquet Jean, Marquis Martin, Williamson David, Fontaine Guillaume, Chauny Jean-Marc, Frégeau Amélie, Orkin Aaron M, Upadhye Suneel, Lessard Justine, Cournoyer Alexis
Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada.
Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada.
Acad Emerg Med. 2023 Dec;30(12):1253-1263. doi: 10.1111/acem.14790. Epub 2023 Sep 7.
Opioids are often prescribed for acute pain to patients discharged from the emergency department (ED), but there is a paucity of data on their short-term use. The purpose of this study was to synthesize the evidence regarding the efficacy of prescribed opioids compared to nonopioid analgesics for acute pain relief in ED-discharged patients.
MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL, and gray literature databases were searched from inception to January 2023. Two independent reviewers selected randomized controlled trials investigating the efficacy of prescribed opioids for ED-discharged patients, extracted data, and assessed risk of bias. Authors were contacted for missing data and to identify additional studies. The primary outcome was the difference in pain intensity scores or pain relief. All meta-analyses used a random-effect model and a sensitivity analysis compared patients treated with codeine versus those treated with other opioids.
From 5419 initially screened citations, 46 full texts were evaluated and six studies enrolling 1161 patients were included. Risk of bias was low for five studies. There was no statistically significant difference in pain intensity scores or pain relief between opioids versus nonopioid analgesics (standardized mean difference [SMD] 0.12; 95% confidence interval [CI] -0.10 to 0.34). Contrary to children, adult patients treated with opioid had better pain relief (SMD 0.28, 95% CI 0.13-0.42) compared to nonopioids. In another sensitivity analysis excluding studies using codeine, opioids were more effective than nonopioids (SMD 0.30, 95% CI 0.15-0.45). However, there were more adverse events associated with opioids (odds ratio 2.64, 95% CI 2.04-3.42).
For ED-discharged patients with acute musculoskeletal pain, opioids do not seem to be more effective than nonopioid analgesics. However, this absence of efficacy seems to be driven by codeine, as opioids other than codeine are more effective than nonopioids (mostly NSAIDs). Further prospective studies on the efficacy of short-term opioid use after ED discharge (excluding codeine), measuring patient-centered outcomes, adverse events, and potential misuse, are needed.
急诊科（ED）出院的患者常被开具阿片类药物用于缓解急性疼痛，但关于其短期使用的数据较少。本研究的目的是综合有关开具的阿片类药物与非阿片类镇痛药相比，在缓解ED出院患者急性疼痛方面疗效的证据。
检索了MEDLINE、EMBASE、CINAHL、PsycINFO、CENTRAL和灰色文献数据库，检索时间从建库至2023年1月。两名独立的评审员选择了调查开具的阿片类药物对ED出院患者疗效的随机对照试验，提取数据并评估偏倚风险。联系作者获取缺失数据并识别其他研究。主要结局是疼痛强度评分或疼痛缓解的差异。所有荟萃分析均采用随机效应模型，敏感性分析比较了接受可待因治疗的患者与接受其他阿片类药物治疗的患者。
从最初筛选的5419篇文献中，评估了46篇全文，纳入了6项研究，共1161名患者。5项研究的偏倚风险较低。阿片类药物与非阿片类镇痛药在疼痛强度评分或疼痛缓解方面无统计学显著差异（标准化均值差[SMD]0.12；95%置信区间[CI]-0.10至0.34）。与儿童相反，与非阿片类药物相比，接受阿片类药物治疗的成年患者疼痛缓解更好（SMD 0.28，95%CI 0.13-0.42）。在另一项排除使用可待因研究的敏感性分析中，阿片类药物比非阿片类药物更有效（SMD 0.30，95%CI 0.15-0.45）。然而，与阿片类药物相关的不良事件更多（优势比2.64，95%CI 2.04-3.42）。
对于ED出院的急性肌肉骨骼疼痛患者，阿片类药物似乎并不比非阿片类镇痛药更有效。然而，这种疗效的缺乏似乎是由可待因导致的，因为除可待因外的阿片类药物比非阿片类药物（主要是非甾体抗炎药）更有效。需要进一步进行前瞻性研究，以探讨ED出院后短期使用阿片类药物（不包括可待因）的疗效，测量以患者为中心的结局、不良事件和潜在的滥用情况。
