IV Hydromorphone vs IV Acetaminophen for Severe Acute Pain in the ED

Intravenous (IV) hydromorphone may provide greater analgesic effect compared with IV acetaminophen in adult patients presenting to the emergency department with severe acute pain, according to a study published in the Annals of Emergency Medicine.

For this double-blind, randomized prospective trial, which was carried out in 2 urban academic emergency departments between June and November 2017, 220 patients aged 21 to 64 years who presented with severe acute pain were enrolled. Participants were randomly assigned to receive hydromorphone 1 mg (n=110; 58% women; mean age, 42 years), or acetaminophen 1 g (n=110; 62% women; mean age, 43 years). A 0 to 10 numeric rating scale (NRS) was used to rate pain intensity at baseline and 60 minutes after medication infusion. The primary outcome was the difference in NRS change reported more than 60 minutes between the 2 treatment groups, and secondary outcomes were requests for additional medication and occurrence of adverse events.

Of 220 participants, 206 individuals (103 in each group) were included for analysis. An hour after infusion, the mean NRS score reductions were 5.3 and 3.3 in the hydromorphone and acetaminophen groups, respectively (difference in NRS scores, 2.0; 95% CI, 1.2-2.7). More patients who received hydromorphone vs acetaminophen refused additional analgesic relief after 60 minutes (65% vs 44%, respectively; 21% difference; 95% CI, 8%-35%). Requests for rescue analgesia before 60 minutes were infrequent and equivocal in both groups. Study participants in the hydromorphone vs acetaminophen group reported more nausea (19% vs 3%, respectively; 16% difference; 95% CI, 4%-28%) and vomiting (14% vs 3%, respectively; 11% difference; 95% CI, 0%-23%), and patients in both groups experienced similar low levels of pruritus.

Study limitations included failure to identify patients for whom either drug may be indicated/contraindicated, substantial practice variation and prescribing tendencies among physicians, bias toward more severe pain cases, and potential nongeneralizability of results to other populations and settings.

“Although both 1 mg intravenous hydromorphone and 1 g intravenous acetaminophen provided clinically meaningful reductions in pain scores, treatment with hydromorphone provided both clinically and statistically greater analgesia than acetaminophen, at the cost of a higher incidence of nausea and vomiting,” summarized the authors.

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Reference

Barnaby DP, Chertoff AE, Restivo AJ, et al. Randomized controlled trial of intravenous acetaminophen versus intravenous hydromorphone for the treatment of acute pain in the emergency department. Ann Emerg Med. August 2018:1-8. doi:10.1016/j.annemergmed.2018.06.019