A systematic review of 42 academic research articles has found that the risk-benefit balance of using opioids to treat musculoskeletal pain in the emergency department (ED) setting remains unclear. The review is published in Annals of Internal Medicine.

Opioid analgesics are commonly administered in EDs to manage pain and may be prescribed upon discharge for short-term pain management, with a goal of rapid pain control and avoidance of hospitalizaiton.

However, many patients who later experience opioid dependence, overdose, and death first interact with these medications in ED settings. There is debate about the appropriate use of opioids to treat pain outside of ED settings, but guidelines do not address the differences in expected benefits and harms of opioids versus nonopioid analgesics.

Researchers from the University of Sydney reviewed 42 articles studying the application of opioids in ED settings to evaluate the comparative effectiveness and harms of opioids for musculoskeletal pain in this setting.

They found that opioids may provide statistically but not clinically greater pain relief compared with placebo and paracetamol but are no more effective than some nonopioid options, particularly NSAIDs, across a range of musculoskeletal condition categories. They also report that opioids were associated with more adverse outcomes than placebo, paracetamol, and NSAIDs, but certainty was low.

The authors advise that their analysis of adverse events suggests that clinicians should be cautious about replacing opioids with anesthetics, such as ketamine.

They also add that future research in this area should consider including measures of other outcomes of interest to ED clinicians and policymakers, such as rate of hospitalization, and potential harms, such as long-term opioid use after initiation in the ED.