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Treatments for Acute Pain: A Systematic Review
Comparative Effectiveness Review, No. 240
Investigators: Roger Chou, M.D., Jesse Wagner, M.A., Azrah Y. Ahmed, B.A., Ian Blazina, M.P.H., Erika Brodt, B.S., David I. Buckley, M.D., M.P.H., Tamara P. Cheney, M.D., Esther Choo, M.D., M.P.H., Tracy Dana, M.L.S., Debra Gordon, R.N., D.N.P., FANN, Saurabh Khandelwal, M.D., Shelby Kantner, B.A., Marian S. McDonagh, Pharm.D., Christine Sedgley, M.D.S., M.D.Sc., FRACDS, MRACDS (ENDO), FACD, Ph.D., and Andrea C. Skelly, Ph.D., M.P.H.
Structured Abstract
Objectives:
To evaluate the effectiveness and comparative effectiveness of opioid, nonopioid pharmacologic, and nonpharmacologic therapy in patients with specific types of acute pain, including effects on pain, function, quality of life, adverse events, and long-term use of opioids.
Data sources:
Electronic databases (Ovid® MEDLINE®, PsycINFO®, Embase®, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews) to August 2020, reference lists, and a Federal Register notice.
Review methods:
Using predefined criteria and dual review, we selected randomized controlled trials (RCTs) of outpatient therapies for eight acute pain conditions: low back pain, neck pain, other musculoskeletal pain, neuropathic pain, postoperative pain following discharge, dental pain (surgical or nonsurgical), pain due to kidney stones, and pain due to sickle cell disease. Meta-analyses were conducted on pharmacologic therapy for dental pain and kidney stone pain, and likelihood of repeat or rescue medication use and adverse events. The magnitude of effects was classified as small, moderate, or large using previously defined criteria, and strength of evidence was assessed.
Results:
One hundred eighty-three RCTs on the comparative effectiveness of therapies for acute pain were included. Opioid therapy was probably less effective than nonsteroidal anti-inflammatory drugs (NSAIDs) for surgical dental pain and kidney stones, and might be similarly effective as NSAIDs for low back pain. Opioids and NSAIDs were more effective than acetaminophen for surgical dental pain, but opioids were less effective than acetaminophen for kidney stone pain. For postoperative pain, opioids were associated with increased likelihood of repeat or rescue analgesic use, but effects on pain intensity were inconsistent. Being prescribed an opioid for acute low back pain or postoperative pain was associated with increased likelihood of use of opioids at long-term followup versus not being prescribed, based on observational studies. Heat therapy was probably effective for acute low back pain, spinal manipulation might be effective for acute back pain with radiculopathy, acupressure might be effective for acute musculoskeletal pain, an opioid might be effective for acute neuropathic pain, massage might be effective for some types of postoperative pain, and a cervical collar or exercise might be effective for acute neck pain with radiculopathy. Most studies had methodological limitations. Effect sizes were primarily small to moderate for pain, the most commonly evaluated outcome. Opioids were associated with increased risk of short-term adverse events versus NSAIDs or acetaminophen, including any adverse event, nausea, dizziness, and somnolence. Serious adverse events were uncommon for all interventions, but studies were not designed to assess risk of overdose, opioid use disorder, or long-term harms. Evidence on how benefits or harms varied in subgroups was lacking.
Conclusions:
Opioid therapy was associated with decreased or similar effectiveness as an NSAID for some acute pain conditions, but with increased risk of short-term adverse events. Evidence on nonpharmacological therapies was limited, but heat therapy, spinal manipulation, massage, acupuncture, acupressure, a cervical collar, and exercise were effective for specific acute pain conditions. Research is needed to determine the comparative effectiveness of therapies for sickle cell pain, acute neuropathic pain, neck pain, and management of postoperative pain following discharge; effects of therapies for acute pain on non-pain outcomes; effects of therapies on long-term outcomes, including long-term opioid use; and how benefits and harms of therapies vary in subgroups.
Contents
- Preface
- Acknowledgments
- Technical Expert Panel
- Peer Reviewers
- Evidence Summary
- Introduction
- Methods
- Results
- Key Question (KQ) 1. Acute Back Pain (Including Back Pain With Radiculopathy)
- KQ 2. Acute Neck Pain (Including Neck Pain With Radiculopathy)
- KQ 3. Musculoskeletal Pain Not Otherwise Included in KQ1 or KQ2 (Including Fractures)
- KQ 4. Peripheral Neuropathic Pain (Related to Herpes Zoster and Trigeminal Neuralgia)
- KQ 5. Postoperative Pain (Excluding Inpatient Management of Pain Following Major Surgical Procedures)
- KQ 6. Dental Pain (Surgical and Nonsurgical After Discharge)
- KQ 7. Kidney Stone Pain
- KQ 8. Sickle Cell Crisis
- Discussion
- References
- Abbreviations and Acronyms
- Appendixes
Suggested citation:
Chou R, Wagner J, Ahmed AY, Blazina I, Brodt E, Buckley DI, Cheney TP, Choo E, Dana T, Gordon D, Khandelwal S, Kantner S, McDonagh MS, Sedgley C, Skelly AC. Treatments for Acute Pain: A Systematic Review. Comparative Effectiveness Review No. 240. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No. 20(21)-EHC006. Rockville, MD: Agency for Healthcare Research and Quality; December 2020. DOI: https://doi.org/10.23970/AHRQEPCCER240. Posted final reports are located on the Effective Health Care Program search page.
This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2015-00009-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.
AHRQ appreciates appropriate acknowledgment and citation of its work. Suggested language for acknowledgment: This work was based on an evidence report, Treatments for Acute Pain: A Systematic Review, by the Evidence-based Practice Center Program at the Agency for Healthcare Research and Quality (AHRQ).
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