Opioids for Treatment of Pre-hospital Acute Pain: A Systematic Review

Abstract

Introduction: Acute pain is a frequent symptom among patients in the pre-hospital setting, and opioids are the most widely used class of drugs for the relief of pain in these patients. However, the evidence base for opioid use in this setting appears to be weak. The aim of this systematic review was to explore the efficacy and safety of opioid analgesics in the pre-hospital setting and to assess potential alternative therapies.

Methods: The PubMed, EMBASE, Cochrane Library, Centre for Reviews and Dissemination, Scopus, and Epistemonikos databases were searched for studies investigating adult patients with acute pain prior to their arrival at hospital. Outcomes on efficacy and safety were assessed. Risk of bias for each included study was assessed according to the Cochrane approach, and confidence in the evidence was assessed using the GRADE method.

Results: A total of 3453 papers were screened, of which the full text of 125 was assessed. Twelve studies were ultimately included in this systematic review. Meta-analysis was not undertaken due to substantial clinical heterogeneity among the included studies. Several studies had high risk of bias resulting in low or very low quality of evidence for most of the outcomes. No pre-hospital studies compared opioids with placebo, and no studies assessed the risk of opioid administration for subgroups of frail patients. The competency level of the attending healthcare provider did not seem to affect the efficacy or safety of opioids in two observational studies of very low quality. Intranasal opioids had a similar effect and safety profile as intravenous opioids. Moderate quality evidence supported a similar efficacy and safety of synthetic opioid compared to morphine.

Conclusions: Available evidence for pre-hospital opioid administration to relieve acute pain is scarce and the overall quality of evidence is low. Intravenous administration of synthetic, fast-acting opioids may be as effective and safe as intravenous administration of morphine. More controlled studies are needed on alternative routes for opioid administration and pre-hospital pain management for potentially more frail patient subgroups.

Keywords: Acute pain; Emergency medicine; Opioids; Pre-hospital.

Fig. 1

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram of study selection

Fig. 2

Risk of bias table. Obs Observational study, qRCT quasi-RCT, RCT randomized controlled trial

Fig. 3

Forest plot illustrating change in pain scores for patients treated with synthetic opioids vs. morphine. CI Confidence interval, i.v. intravenous, SD standard deviation

Fig. 4

Forest plot illustrating adverse events in patients treated with synthetic opioids vs. morphine. RCT randomized controlled trial, qRCT quasi-RCT, Obs observational study, AE standard adverse events, i.v. intravenous, CI confidence interval, vs versus

Fig. 5

Forest plot illustrating change in pain scores for patients treated by physicians versus paramedics. SD standard deviation, i.v. intravenous, CI confidence interval, vs versus