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Am Fam Physician. 2021;104(1):95-96

Clinical Question

What oral analgesic provides the best, immediate relief for acute muscle pain?

Bottom Line

A single dose of opioid analgesics provides similar acute pain relief compared with a single dose of a combination of acetaminophen and ibuprofen in patients with acute musculoskeletal pain in the emergency department. Opioids increase the likelihood of nausea or vomiting. There was no added benefit of 800 mg of ibuprofen compared with 400 mg. The study did not investigate the effect of an injectable analgesic, possibly because of the placebo effect. These results are similar to those of previous studies of opioids and different doses of ibuprofen. (Level of Evidence = 1b)


The researchers enrolled 600 adults, primarily Latino, presenting to two emergency departments with a sprain, strain, fracture, or other musculoskeletal extremity pain, excluding back pain. The patients were randomly assigned, using concealed allocation, to receive a single dose of one of five combinations of analgesics: 1,000 mg of acetaminophen with either 400 mg or 800 mg of ibuprofen, 300 mg of acetaminophen with 30 mg of codeine, 300 mg of acetaminophen with 5 mg of hydrocodone, or 325 mg of acetaminophen with 5 mg of oxycodone. Pain scores before treatment were mostly 8 to 10 on a scale of 0 to 10 (with 10 being the worst pain). Pain scores dropped an average of three points in every group by 60 minutes after the medication dose, with no statistical difference among the groups. Within two hours, the decrease from baseline was an average 4.3 to 4.7 points, with no significant differences among the groups. A similar percentage of patients in each group (24%) received rescue pain medication within the first two hours. The likelihood of nausea or vomiting was significantly higher among patients who received an opioid analgesic, with one additional patient experiencing these adverse effects for every 25 patients treated with an opioid (number needed to treat = 20; 95% CI, 12 to 59). The study had the power to detect a difference of 1.3 points between treatments, if one existed.

Study design: Randomized controlled trial (double-blinded)

Funding source: Foundation

Allocation: Concealed

Setting: Emergency department

Reference: Bijur PE, Friedman BW, Irizarry E, et al. A randomized trial comparing the efficacy of five oral analgesics for treatment of acute musculoskeletal extremity pain in the emergency department. Ann Emerg Med. 2021;77(3):345–356.

Editor's Note: Dr. Shaughnessy is an assistant medical editor for AFP.

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see Copyright Wiley-Blackwell. Used with permission.

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