Hydrocodone Versus Codeine for Pain Management After Emergency Department (ED) Discharge

• Overall Satisfaction with the pain medicine [ Time Frame: 24 hrs ] [ Designated as safety issue: No ]
  Overall satisfaction with the oral opioid pain medication at 24 hours after discharge using a Likert scale. Patients will be asked to describe their overall experience as being very satisfied, satisfied, unsatisfied or very unsatisfied with the study medication.
• Side Effects [ Time Frame: 24 hrs ] [ Designated as safety issue: Yes ]
  Types and numbers of side effects experienced and average pain scores over the 24 hours after ED discharge.

• Overall satisfaction with the pain medicine [ Time Frame: 24 hrs ] [ Designated as safety issue: No ]
  Overall satisfaction with the oral opioid pain medication at 24 hours after ED discharge using a Likert scale. Patients will be asked to describe their overall experience as being very satisfied, satisfied, unsatisfied, or very unsatisfied with the study medication.
• Side Effects [ Time Frame: 24 hrs ] [ Designated as safety issue: Yes ]
  Types and numbers of side effects experienced and average pain scores over the 24 hours after ED discharge.

The goal of this randomized, double blinded clinical trial is to determine which of two commonly prescribed oral opioid combinations, hydrocodone 5mg / acetaminophen 500mg or codeine 30mg/acetaminophen 300mg, is most effective in managing acute extremity pain after discharge from the adult emergency department.

Eligible patients are those between the ages of 21 and 64 who present to the Emergency Department (ED) with a complaint of acute extremity pain of less than seven days duration in one or more extremities and for whom the clinician plans to discharge on an oral opioid for pain management. Patients will be excluded if they have ever taken methadone; have a chronic condition requiring frequent pain management such as sickle cell disease, fibromyalgia, or any neuropathy; report a history of an adverse reaction to any of the study medications; if they have taken prescribed opioids in the past 24 hours or if they report having ever taken recreational narcotics; if they have a medical condition that might affect their metabolism of opioid analgesics or acetaminophen; or if they take any medicine that might interact with one of the study medications. Patients will be referred by the attending physician or clinician and consent as well as the initial and follow-up data collections will be obtained by our team of trained bilingual (Spanish and English) salaried research associates who staff the ED 24 hours a day and 7 days a week.

Once enrolled, patients will be randomized to one of two experimental groups: hydrocodone 5mg / acetaminophen 500mg or codeine 30mg / acetaminophen 300mg. Randomization will be performed in blocks of 10 and determined by a sequence generated at http://www.randomization.com. The pharmacist working in an area inaccessible to ED staff will ensure proper blinding of the study by masking the medication and inserting it into unmarked gel capsules and filling any void with small amounts of lactose. A three-day supply (18 doses) of the blinded medications will be dispensed by the ED staff to the patient in the order determined by randomization accompanied by instructions to use one tablet of the medication every 4 hours as needed for pain and to avoid use of any other analgesics.

Using a power of 80%, a significance criterion of 0.5, and an estimated delta of 1.3 NRS units, a sample size of 85 patients per group. In order to account for those that do not end up taking the medicine, it is estimated that 120 patients per group will have to be enrolled.

Data will be collected on a standardized data collection instrument, entered by a trained data clerk, and reviewed and audited for accuracy and completeness. The investigators will calculate descriptive statistics for all variables: frequencies, means and standard deviations, medians and IQR, and proportions. Chi-square tests will be used to test differences between dichotomous variables, t-tests will be used to test mean differences. Multivariate models will be used if there are background variables that are unevenly distributed between the two groups. Variables associated with group membership with probability of 0.20 or less will be included in OLS multivariate regression or logistic regression models in order to test the role of group membership while accounting for chance baseline disparities. Interaction terms will be tested and dropped from the models if they were not statically significant at the 0.05 level. SPSS version 17 (Chicago, IL.) will be used to conduct all data analyses.

• Experimental: Hydrocodone
  Hydrocodone 5mg / Acetaminophen 500mg. Patients instructed to take 1 dose every 4 hrs as needed for pain.
  Intervention: Drug: Oral Opioid Pain Medicine
• Active Comparator: Codeine
  Codeine 30mg / Acetaminophen 300mg. Patients instructed to take 1 dose every 4 hrs as needed for pain.
  Intervention: Drug: Oral Opioid Pain Medicine

Inclusion Criteria:

• patient has complaint of acute extremity pain (less than 7 days duration)
• clinician plans to discharge on oral pain medication

Exclusion Criteria:

• patients on methadone
• chronic pain condition such as sickle cell anemia or fibromyalgia
• history of adverse reaction to one of the study medications
• taken prescribed opioids in the past 24 hrs
• have a medical condition that might alter the metabolism of one of the study medications (i.e. hepatitis, renal insufficiency, thyroid disease, Adrenal disease)
• Take a medication that might interact with one of the study medications