Author: Dr. Paul Young Edemobi


In the United States there is an opioid epidemic affecting thousands of people. However, the mainstay of severe treatment of pain still remains to be opioids.

The article looks into acute extremity pain which is one of the most common presentations in the ED. Patients will tend to get an opioid treatment if their pain is deemed to be very uncomfortable for the patient. The study attempts to ascertain if the combination of ibuprofen and acetaminophen may represent a viable non-opioid alternative

Study Question: Which analgesic combination provides pain relief?

(ibuprofen and acetaminophen, oxycodone and acetaminophen, hydrocodone and acetaminophen ,codeine and acetaminophen)


Randomized clinical trial

416 patients

4 groups of 104 each

Location: Montefiore ED in the Bronx and New York

Year: July 2015- August 2016

Pain Measure: NRS pain scale

Minimum clinically important difference: 1.3


The mean NRS pain score decrease in 2 hours:
4.3 (95% CI, 3.6 to 4.9) with ibuprofen and  acetaminophen group
 4.4 (95% CI, 3.7 to 5.0) with oxycodone and acetaminophen group
3.5 (95% CI, 2.9 to 4.2) with hydrocodone and acetaminophen
3.9 (95% CI, 3.2 to 4.5) with codeine and acetaminophen

There were no statistically significant or clinically important differences in pain reduction at 2 hours between the groups

The largest difference in decline in the NRS pain score from baseline to 2 hours was between the oxycodone and acetaminophen group and the hydrocodone and acetaminophen group (0.9; 99.2% CI, −0.1 to 1.8), which was less than the minimum clinically important difference in NRS pain score of 1.3.


The article studies the analgesic effects in 4 different combinations of analgesics.

The results proved that no one single combination proved to be superior than the other.

The study has a few limitations;

18% of patients received rescue analgesia which may have driven results toward the null

The oral opioid administered the equivalent of 1 tablet. Higher doses of opioids could provide better pain relieve.

Duration of analgesics- Patients were only observed for 2 hours. It is unknown if pain was better controlled after 2 hours

Take Away:

This article shows there is no superior benefit between either one of the combinations. This article may change the way I prescribe pain medication in the appropriate clinical setting.

I would be more inclined to use combination of Tylenol and ibuprofen before low dose opioids. However, if patients’ pain is not well controlled transitions into opioids will be appropriate.


Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial. JAMA. 2017 Nov 7;318(17):1661-1667. doi: 10.1001/jama.2017.16190. PMID: 29114833; PMCID: PMC5818795.

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