Nonopioid Pain Management in the ED: Evidence on Opioid Alternatives
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Emergency Department Pain Management: Beyond Opioids

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Table of Contents
 
About This Issue

Although all emergency clinicians are aware of the serious public health crises that prescription opioid overuse and misuse cause, knowing what the evidence shows about the effectiveness and safety of nonpharmacologic and pharmacologic analgesia strategies will help guide you to treatment that is safer and more effective.

Which types of pain scales are most effective – visual, numeric, or functional?

What are some simple, nonpharmacologic pain management strategies that you can use to augment or reduce systemic analgesia use?

What are the most effective nonopioid drug combinations?

Which NSAIDs are safest for use in patients with gastrointestinal, renal, and cardiac risk factors?

When should alternative analgesics be considered: acetaminophen, ketamine, clonidine, and droperidol?

What is the latest evidence on systemically administered lidocaine?

When, where, and how can regional anesthesia be best used for pain control?

What are some of the special recommendations for patients with headache, renal colic, low back pain, and neuropathic pain?

How should you approach pain management in the patient with opioid-use disorder?

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. History of the Opioid Epidemic
  6. Pathophysiology
  7. Prehospital Care
  8. Emergency Department Evaluation
  9. Treatment
    1. Nonpharmacologic Pain Management
    2. Systemic Analgesia
      1. Nonsteroidal Anti-Inflammatory Drugs
        • Gastrointestinal Effects of NSAIDs
        • Renal Effects of NSAIDs
        • Cardiac Effects of NSAIDs
        • Orthopedic Effects of NSAIDs
        • Safety of NSAIDs
        • Topical NSAIDs
      2. Acetaminophen
      3. Dissociatives
      4. Alpha-2 Agonists
      5. Butyrophenones
      6. Systemic Local Anesthetics
    3. Regional Anesthesia
      1. Agents for Regional Anesthesia
        • Topical Anesthesia
        • Local Infiltration
      2. Regional Nerve Blocks
  10. Special Circumstances
    1. Headache
      1. Metoclopramide
      2. Prochlorperazine
      3. Sumatriptan
      4. Ketorolac
      5. Haloperidol and Droperidol
      6. Ketamine
      7. Dexamethasone
      8. Peripheral Nerve Blocks
      9. Lower Cervical Paraspinous Injection
      10. Recommendations for Headache Pain Management
    2. Renal Colic
      1. NSAIDs
      2. Acetaminophen
      3. Desmopressin
      4. Alpha-Adrenergic Receptor Blockers
      5. Recommendations for Renal Colic Pain
    3. Low Back Pain
      1. Benzodiazepines/Muscle Relaxants
      2. Trigger Point Injections
    4. Neuropathic Pain
    5. Managing Pain in Patients With Opioid-Use Disorder
  11. Controversies and Cutting Edge
    1. Cannabis and Cannabinoids
    2. Virtual Reality
  12. Time- and Cost-Effective Strategies
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls for Nonopioid Pain Management
  16. Case Conclusions
  17. Clinical Pathway for Nonopioid Emergency Department Management of Pain
  18. Tables and Figures
    1. Table 1. Tools to Assess Pain and its Interference in Functional Capacities
    2. Table 2. Nonopioid Analgesic Agents
    3. Table 3. Gastrointestinal Risk Versus Cardiovascular Risk for NSAID Use
    4. Table 4. Selected Topical and Local Anesthetic Agents
    5. Table 5. Nerves and Anatomical Areas Amenable to Regional Nerve Blocks
    6. Figure 1. Opioid Overdose Deaths, 1999-2016
    7. Figure 2. Pathophysiology of Pain
    8. Figure 3. Hematoma Block
  19. References

Abstract

Pain is a common factor in many emergency department visits. While opioids remain a mainstay of treatment for many patients, prescription-opioid overuse and misuse have become epidemic in the United States. A lack of clear understanding of the pain management options available contributes to this problem, resulting in opioid overuse and over-prescription. National guidelines and consensus statements emphasize the importance of knowing nonopioid pharmacological and nonpharmacological options for treating patients with acute pain. This evidence-based review summarizes the pathophysiology of pain and pain syndromes and provides recommendations for a variety of nonopioid treatment options.

Case Presentations

A 73-year-old woman with a history of peptic ulcer disease and stage 3 chronic kidney disease presents to the ED after “twisting” her ankle. She tried acetaminophen at home, but it didn’t adequately alleviate her pain. Currently, she complains of 6/10 pain at rest. She has mild swelling and tenderness at the posterior edge of her lateral malleolus. You order an ankle x-ray to evaluate for fracture and consider giving her oxycodone, but you wonder whether there is a better and safer alternative…

While you are waiting for the x-ray, a 42-year-old woman with a history of chronic lymphoma-associated back pain presents with an exacerbation of her back pain. She denies recent trauma, weight loss, paresthesia or weakness, and bowel or bladder incontinence or retention, and she tells you this pain is similar to her usual pain. She mentions that she was robbed today, and her pain medication (oxycodone) was stolen, and she asks for a refill. She states that since it is a weekend, her primary care doctor’s office is closed. The ED is packed, and you are tempted to simply refill the prescription, but you wonder whether there is a better option…

As you finish evaluating the second patient, an 85-year-old man presents with pain at his left torso and flank. He states that he was diagnosed with herpes zoster a month ago and has been on oxycodone for 4 weeks. He describes the pain as continuous, burning pain with episodes of severe, stabbing pain that last for seconds. He states that everything exacerbates his pain, even light touch. You expose the patient and see scarring consistent with healing varicella zoster virus infection limited to 1 dermatome, and his skin appears to be intact. The patient drove himself to the ED, and he lives alone at home. He states that the oxycodone is the only thing that gives him any relief. You wonder whether there are management techniques that might mitigate the pain without the complications associated with opioid use…

Introduction

Pain is one of the most common presenting complaints to the emergency department (ED), representing up to 45% of visits in the United States.1 Pain has a significant economic impact, and is responsible for an estimated $47 billion dollars in direct medical costs for treatment.2 Opioid pain medications are some of the most commonly used agents for managing pain, and their simplicity and efficacy may contribute to other treatment options being overlooked. The term opioid refers to medications that act upon opioid receptors, while opiate refers to an agent derived from opium, and is not inclusive of synthetic and semisynthetic derivatives such as fentanyl and hydromorphone. Opioid is the currently accepted inclusive term for these types of drugs. Narcotic is a legal classification, and does not have a precise medical definition.

Opioid misuse and abuse resulted in the death of more than 42,000 people in the United States in 2016, representing two-thirds of all known drug overdose deaths.3 Over 40% of all opioid-related deaths resulted from prescription opioid misuse, which equates to approximately 46 deaths per day.4,5 Since 1999, overdose deaths related to prescription opioids have been increasing steadily. Interestingly, when there was a slight decrease around 2010, deaths from heroin rose dramatically. (See Figure 1.) This is possibly the result of substitution, as prescription opioids became more difficult to obtain.

 

It is challenging for the emergency clinician to manage expectations and symptoms while educating patients about opioid risks and nonopioid options, identifying mental illnesses that can contribute to chronic pain, and connecting patients who have opioid-use disorder to appropriate resources for assistance. This issue of Emergency Medicine Practice provides a foundation for the management of acute pain in the ED. Moreover, it provides different options for nonopioid pain medications, regional anesthesia, and nonpharmacological techniques to alleviate pain, which may help decrease opioid utilization in the ED. For more information on managing pain in pediatric patients, see the August 2019 issue of Pediatric Emergency Medicine Practice, Pediatric Pain Management in the Emergency Department.”

Critical Appraisal of the Literature

A literature search was performed, focusing on articles pertinent to acute pain management in the ED using nonopioid options. Nine hundred sixty articles were identified in MEDLINE® with the search terms acute nonopioid analgesia. Approximately 200 articles were reviewed, of which, 24 systematic reviews, 64 randomized controlled trials, 19 prospective observational studies, and 15 retrospective studies were selected. Additional resources were used, including the Cochrane Database of Systematic Reviews, the Web of Science, The National Guideline Clearinghouse, articles known to the authors, and several textbooks. There is robust evidence supporting the use of multimodal, nonopioid analgesics in the ED. The evidence is especially strong for nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, ketamine, and adjuvant analgesics specific to migraine headache. In contrast, the ED-based literature is less robust on the use of other adjuvant analgesics and nonpharmacologic modalities such as acupuncture, trigger point injections, virtual reality, and mindfulness. Most of the studies on these modalities are small, single-center studies of variable quality.

Risk Management Pitfalls for Nonopioid Pain Management

3. “I didn’t consider regional anesthesia.”

Regional anesthesia is an increasingly popular means of achieving analgesia because it can decrease the amount of systemic analgesia required. It is useful to have a repertoire of familiar and useful techniques to augment some scenarios (eg, dental blocks for dental injuries, digital blocks for finger injuries, etc).

4. “The patient had severe pain from his recurrent kidney stones, and I wanted to avoid opioids, so I gave him 60 mg of IV ketorolac.”

Ketorolac is a nonselective NSAID that can be given parenterally. Ketorolac was commonly dosed at 30 mg IV and 60 mg IM, but recently it was established that the ceiling analgesic dose was actually 10 mg IV and IM. Increasing doses beyond this does not add any analgesic benefit but increases side effects.

6. “The patient was agitated, but I didn’t consider pain as the etiology.”

Many times, patients are unable to communicate their discomfort adequately (such as with intubated or demented patients). Painful conditions should be considered as a cause of increased agitation or delirium.

Tables and Figures

Table 2. Nonopioid Analgesic Agents

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

  1. Chang HY, Daubresse M, Kruszewski SP, et al. Prevalence and treatment of pain in EDs in the United States, 2000 to 2010. Am J Emerg Med. 2014;32(5):421-431. (Database review)
  2. Gaskin DJ, Richard P, Institute of Medicine. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Appendix C: the economic costs of pain in the United States. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC): National Academies Press; 2011:301-338. (Institute of Medicine report)
  3. Wide-ranging Online Data for Epidemiologic Research (WONDER). US Department of Health and Human Services, Centers for Disease Control and Prevention; 2016. Accessed October 10, 2019. (Government database)
  4. Seth P, Rudd RA, Noonan RK, et al. Quantifying the epidemic of prescription opioid overdose deaths. Am J Public Health. 2018;108(4):500-502. (Database review)
  5. Seth P SL, Rudd RA, Bacon S. Increases and geographic variations in overdose deaths involving opioids, cocaine, and psychostimulants with abuse potential – United States, 2015-2016. MMWR Morb Mortal Wkly Rep. ePub. 2018. (Database review)
  6. Jones MR, Viswanath O, Peck J, et al. A brief history of the opioid epidemic and strategies for pain medicine. Pain Ther. 2018;7(1):13-21. (Review)
  7. Campbell JN. APS 1995 Presidential address. Pain Forum. 1996;5(1):85-88. (Address)
  8. Phillips D. JCAHO pain management standards are unveiled. JAMA. 2000;2000(284):428-429. (Medical news)
  9. Van Zee A. The promotion and marketing of oxycontin: commercial triumph, public health tragedy. Am J Public Health. 2009;99(2):221-227. (Review)
  10. Meier B. In Guilty Plea, OxyContin Maker to Pay $600 Million. The New York Times. May 10, 2007. (News article)
  11. Baker DW. History of the Joint Commission’s pain standards: lessons for today’s prescription opioid epidemic. JAMA. 2017;317(11):1117-1118. (Review)
  12. White LJ, Cooper JD, Chambers RM, et al. Prehospital use of analgesia for suspected extremity fractures. Prehosp Emerg Care. 2000;4(3):205-208. (Retrospective study; 1073 patients)
  13. McEachin CC, McDermott JT, Swor R. Few emergency medical services patients with lower-extremity fractures receive prehospital analgesia. Prehosp Emerg Care. 2002;6(4):406-410. (Retrospective study; 124 patients)
  14. Jennings PA, Cameron P, Bernard S, et al. Morphine and ketamine is superior to morphine alone for out-of-hospital trauma analgesia: a randomized controlled trial. Ann Emerg Med. 2012;59(6):497-503. (Prospective randomized study; 135 patients)
  15. Schauer SG, Mora AG, Maddry JK, et al. Multicenter, prospective study of prehospital administration of analgesia in the U.S. combat theater of Afghanistan. Prehosp Emerg Care. 2017:1-6. (Prospective study; 532 patients)
  16. Bronsky ES, Koola C, Orlando A, et al. Intravenous low-dose ketamine provides greater pain control compared to fentanyl in a civilian prehospital trauma system: a propensity matched analysis. Prehosp Emerg Care. 2018:1-8. (Retrospective study; 200 patients)
  17. Barker R, Schiferer A, Gore C, et al. Femoral nerve blockade administered preclinically for pain relief in severe knee trauma is more feasible and effective than intravenous metamizole: a randomized controlled trial. J Trauma. 2008;64(6):1535-1538. (Prospective randomized study; 52 patients)
  18. McRae PJ, Bendall JC, Madigan V, et al. Paramedic-performed fascia iliaca compartment block for femoral fractures: A controlled trial. J Emerg Med. 2015;48(5):581-589. (Prospective randomized study; 24 patients)
  19. Lang T, Hager H, Funovits V, et al. Prehospital analgesia with acupressure at the Baihui and Hegu points in patients with radial fractures: a prospective, randomized, double-blind trial. Am J Emerg Med. 2007;25(8):887-893. (Prospective randomized study; 32 patients)
  20. Kober A, Scheck T, Greher M, et al. Prehospital analgesia with acupressure in victims of minor trauma: a prospective, randomized, double-blinded trial. Anesth Analg. 2002;95(3):723-727. (Prospective randomized study; 60 patients)
  21. Bijur PE, Silver W, Gallagher EJ. Reliability of the visual analog scale for measurement of acute pain. Acad Emerg Med. 2001;8(12):1153-1157. (Prospective study; 96 patients)
  22. Bijur P, Latimer C, Gallagher E. Validation of a verbally administered numerical rating scale of acute pain for use in the emergency department. Acad Emerg Med. 2003;10(4):390-392. (Prospective cohort; 108 patients)
  23. Im DD, Jambaulikar G, Kikut A, et al. 237 a new method for assessing pain in the emergency department. Ann Emerg Med. 2017;70(4):S94. (Abstract, ACEP Research Forum)
  24. Suraseranivongse S, Santawat U, Kraiprasit K, et al. Cross-validation of a composite pain scale for preschool children within 24 hours of surgery. Br J Anaesth. 2001;87(3):400-405. (Cross-validation; 167 pediatric patients)
  25. Merkel S, Voepel-Lewis T, Shayevitz J, et al. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs. 1997;23(3):293-297. (Observational; 89 children)
  26. Tousignant-Laflamme Y, Rainville P, Marchand S. Establishing a link between heart rate and pain in healthy subjects: a gender effect. J Pain. 2005;6(6):341-347. (Observational; 39 volunteers)
  27. Warden V, Hurley A, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc. 2003:4:9-15. (Prospective; 19 patients)
  28. Sakamoto JT, Ward HB, Vissoci JRN, et al. Are nonpharmacologic pain interventions effective at reducing pain in adult patients visiting the emergency department? A systematic review and meta-analysis. Acad Emerg Med. 2018;25(8):940-957. (Systematic review; 56 studies)
  29. Grissa MH, Baccouche H, Boubaker H, et al. Acupuncture vs intravenous morphine in the management of acute pain in the ED. Am J Emerg Med. 2016;34(11):2112-2116. (Prospective randomized study; 300 patients)
  30. Arnold AA, Ross BE, Silka PA. Efficacy and feasibility of acupuncture for patients in the ED with acute, nonpenetrating musculoskeletal injury of the extremities. Am J Emerg Med. 2009;27(3):280-284. (Prospective trial; 20 patients)
  31. Fathi M, Zare MA, Bahmani HR, et al. Comparison of oral oxycodone and naproxen in soft tissue injury pain control: a double-blind randomized clinical trial. Am J Emerg Med. 2015;33(9):1205-1208. (Prospective randomized study; 150 patients)
  32. Chang AK, Bijur PE, Esses D, et al. Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: a randomized clinical trial. JAMA. 2017;318(17):1661-1667. (Prospective randomized study; 416 patients)
  33. Ong CK, Lirk P, Tan CH, et al. An evidence-based update on nonsteroidal anti-inflammatory drugs. Clin Med Res. 2007;5(1):19-34. (Review)
  34. Seymour RA, Ward-Booth P, Kelly PJ. Evaluation of different doses of soluble ibuprofen and ibuprofen tablets in postoperative dental pain. Br J Oral Maxillofac Surg. 1996;34(1):110-114. (Prospective randomized study; 148 patients)
  35. Motov S, Masoudi A, Drapkin J, et al. Comparison of oral ibuprofen at three single-dose regimens for treating acute pain in the emergency department: a randomized controlled trial. Ann Emerg Med. 2019;74(4):530-537. (Randomized double-blind study; 225 patients)
  36. Staquet MJ. A double-blind study with placebo control of intramuscular ketorolac tromethamine in the treatment of cancer pain. J Clin Pharmacol. 1989;29(11):1031-1036. (Prospective randomized study; 126 patients)
  37. Brown CR, Moodie JE, Wild VM, et al. Comparison of intravenous ketorolac tromethamine and morphine sulfate in the treatment of postoperative pain. Pharmacotherapy. 1990;10(6 (Pt 2)):116S-121S. (Prospective randomized study; 122 patients)
  38. Motov S, Yasavolian M, Likourezos A, et al. Comparison of intravenous ketorolac at three single-dose regimens for treating acute pain in the emergency department: a randomized controlled trial. Ann Emerg Med. 2017;70(2):177-184. (Prospective randomized study; 240 patients)
  39. Lanza FL, Chan FK, Quigley EM. Guidelines for prevention of NSAID-related ulcer complications. Am J Gastroenterol. 2009;104(3):728-738. (Guideline)
  40. Richy F, Bruyere O, Ethgen O, et al. Time dependent risk of gastrointestinal complications induced by non-steroidal anti-inflammatory drug use: a consensus statement using a meta-analytic approach. Ann Rheum Dis. 2004;63(7):759-766. (Systematic review and meta-analysis; 45 studies)
  41. Masso Gonzalez EL, Patrignani P, Tacconelli S, et al. Variability among nonsteroidal antiinflammatory drugs in risk of upper gastrointestinal bleeding. Arthritis Rheum. 2010;62(6):1592-1601. (Systematic review)
  42. Yu Y, Ricciotti E, Scalia R, et al. Vascular COX-2 modulates blood pressure and thrombosis in mice. Sci Transl Med. 2012;4(132):132ra154. (Animal model genetic study)
  43. Bresalier RS, Sandler RS, Quan H, et al. Cardiovascular events associated with rofecoxib in a colorectal adenoma chemoprevention trial. N Engl J Med. 2005;352(11):1092-1102. (Prospective randomized study; 2586 patients)
  44. Nissen SE, Yeomans ND, Solomon DH, et al. Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis. N Engl J Med. 2016;375(26):2519-2529. (Prospective randomized study; 24,081 patients)
  45. Bally M, Dendukuri N, Rich B, et al. Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data. BMJ. 2017;357:j1909. (Systematic review)
  46. Bhattacharyya T, Levin R, Vrahas MS, et al. Nonsteroidal antiinflammatory drugs and nonunion of humeral shaft fractures. Arthritis Rheum. 2005;53(3):364-367. (Retrospective study; 9995 patients)
  47. Solomon DH, Rassen JA, Glynn RJ, et al. The comparative safety of analgesics in older adults with arthritis. Arch Intern Med. 2010;170(22):1968-1976. (Retrospective study; 12,840 patients)
  48. Derry S, Wiffen PJ, Kalso EA, et al. Topical analgesics for acute and chronic pain in adults - an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;5:CD008609. (Systematic review; 13 Cochrane reviews, 206 studies, 30,700 participants)
  49. Hinz B, Cheremina O, Brune K. Acetaminophen (paracetamol) is a selective cyclooxygenase-2 inhibitor in man. FASEB J. 2008;22(2):383-390. (Clinical trial; 5 human volunteers)
  50. McNicol ED, Ferguson MC, Haroutounian S, et al. Single dose intravenous paracetamol or intravenous propacetamol for postoperative pain. Cochrane Database Syst Rev. 2016(5):CD007126. (Cochrane review; 75 studies, 7200 patients)
  51. Craig M, Jeavons R, Probert J, et al. Randomised comparison of intravenous paracetamol and intravenous morphine for acute traumatic limb pain in the emergency department. Emerg Med J. 2012;29(1):37-39. (Prospective randomized study; 55 patients)
  52. Jalili M, Mozaffarpour Noori A, Sedaghat M, et al. Efficacy of intravenous paracetamol versus intravenous morphine in acute limb trauma. Trauma Mon. 2016;21(1):e19649. (Prospective randomized study; 60 patients)
  53. Sin B, Wai M, Tatunchak T, et al. The use of intravenous acetaminophen for acute pain in the emergency department. Acad Emerg Med. 2016;23(5):543-553. (Review)
  54. Furyk J, Levas D, Close B, et al. Intravenous versus oral paracetamol for acute pain in adults in the emergency department setting: a prospective, double-blind, double-dummy, randomised controlled trial. Emerg Med J. 2018;35(3):179-184. (Prospective randomized controlled trial; 87 patients)
  55. Chidambaran V, Subramanyam R, Ding L, et al. Cost-effectiveness of intravenous acetaminophen and ketorolac in adolescents undergoing idiopathic scoliosis surgery. Paediatr Anaesth. 2018;28(3):237-248. (Prospective randomized controlled trial; 106 patients)
  56. Blonk KM, Davenport A, Morgan B, et al. Administration of oral acetaminophen to reduce costs for the hysterectomy patient at a community hospital. J Perianesth Nurs. 2019;34(1):143-150. (Retrospective chart review; 46 patients)
  57. Subramanyam R, Varughese A, Kurth CD, et al. Cost-effectiveness of intravenous acetaminophen for pediatric tonsillectomy. Paediatr Anaesth. 2014;24(5):467-475. (Prospective observational study; 139 patients)
  58. McGuinness SK, Wasiak J, Cleland H, et al. A systematic review of ketamine as an analgesic agent in adult burn injuries. Pain Med. 2011;12(10):1551-1558. (Systematic review)
  59. Strayer RJ, Nelson LS. Adverse events associated with ketamine for procedural sedation in adults. Am J Emerg Med. 2008;26(9):985-1028. (Systematic review)
  60. Karlow N, Schlaepfer CH, Stoll CRT, et al. A systematic review and meta-analysis of ketamine as an alternative to opioids for acute pain in the emergency department. Acad Emerg Med. 2018;25(10):1086-1097. (Systematic review and meta-analysis; 3 studies)
  61. Ahern TL, Herring AA, Anderson ES, et al. The first 500: initial experience with widespread use of low-dose ketamine for acute pain management in the ED. Am J Emerg Med. 2015;33(2):197-201. (Retrospective case series; 530 patients)
  62. Bisanzo M, Nichols K, Hammerstedt H, et al. Nurse-administered ketamine sedation in an emergency department in rural Uganda. Ann Emerg Med. 2012;59(4):268-275. (Observational study; 191 patients)
  63. Motov S, Mai M, Pushkar I, et al. A prospective randomized, double-dummy trial comparing IV push low dose ketamine to short infusion of low dose ketamine for treatment of pain in the ED. Am J Emerg Med. 2017;35(8):1095-1100. (Prospective randomized study; 48 patients)
  64. Gerlach AT, Murphy CV, Dasta JF. An updated focused review of dexmedetomidine in adults. Ann Pharmacother. 2009;43(12):2064-2074. (Review)
  65. Richards JR, Richards IN, Ozery G, et al. Droperidol analgesia for opioid-tolerant patients. J Emerg Med. 2011;41(4):389-396. (Review)
  66. Sharma SK, Davies MW. Patient-controlled analgesia with a mixture of morphine and droperidol. Br J Anaesth. 1993;71(3):435-436. (Prospective randomized study; 50 patients)
  67. Yamamoto S, Yamaguchi H, Sakaguchi M, et al. Preoperative droperidol improved postoperative pain relief in patients undergoing rotator-cuff repair during general anesthesia using intravenous morphine. J Clin Anesth. 2003;15(7):525-529. (Prospective randomized study; 84 patients)
  68. Kao LW, Kirk MA, Evers SJ, et al. Droperidol, QT prolongation, and sudden death: what is the evidence? Ann Emerg Med. 2003;41(4):546-558. (Systematic review)
  69. Droperidol Gets Dropped.” Emergency Physicians Monthly. Accessed October 10, 2019. (Website)
  70. American Regent Re-introduces Droperidol Injection, USP; AP Rated and Therapeutically Equivalent to Inapsine®1” MarketWatch. Accessed October 10, 2019. (Website news article)
  71. E Silva LOJ, Scherber K, Cabrera D, et al. Safety and efficacy of intravenous lidocaine for pain management in the emergency department: a systematic review. Ann Emerg Med. 2018;72(2):135-144. (Systematic review; 8 studies, 536 patients)
  72. Auroy Y, Benhamou D, Bargues L, et al. Major complications of regional anesthesia in France: The SOS Regional Anesthesia Hotline Service. Anesthesiology. 2002;97(5):1274-1280. (Prospective; 487 anesthesiologists)
  73. Bhoi S, Sinha TP, Rodha M, et al. Feasibility and safety of ultrasound-guided nerve block for management of limb injuries by emergency care physicians. J Emerg Trauma Shock. 2012;5(1):28-32. (Prospective; 50 patients)
  74. Dillion DC, Gibbs MA. Local and Regional Anesthesia. In: Tintinalli J, Stapczynski J, Ma OJ, et al eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed. New York: McGraw-Hill; 2011. (Textbook chapter)
  75. Campbell D, Adriani J. Absorption of local anesthetics. J Am Med Assoc. 1958;168(7):873-877. (Pharmacodynamic measurement; canine and human subjects)
  76. Fleming JA, O’Connor BD. Use of lidocaine patches for neuropathic pain in a comprehensive cancer centre. Pain Res Manag. 2009;14(5):381-388. (Retrospective chart review; 97 patients)
  77. Cheng YJ. Lidocaine skin patch (lidopat(®) 5%) is effective in the treatment of traumatic rib fractures: a prospective double-blinded and vehicle-controlled study. Med Princ Pract. 2016;25(1):36-39. (Randomized double-blind study; 44 patients)
  78. Ingalls NK, Horton ZA, Bettendorf M, et al. Randomized, double-blind, placebo-controlled trial using lidocaine patch 5% in traumatic rib fractures. J Am Coll Surg. 2010;210(2):205-209. (Randomized double-blind placebo-controlled study; 58 patients)
  79. Zink KA, Mayberry JC, Peck EG, et al. Lidocaine patches reduce pain in trauma patients with rib fractures. Am Surg. 2011;77(4):438-442. (Retrospective cohort; 58 patients)
  80. Hempenstall K, Nurmikko TJ, Johnson RW, et al. Analgesic therapy in postherpetic neuralgia: a quantitative systematic review. PLoS Med. 2005;2(7):e164. (Systematic review and meta-analysis; 25 studies)
  81. Myderrizi N, Mema B. The hematoma block an effective alternative for fracture reduction in distal radius fractures. Med Arh. 2011;65(4):239-242. (Prospective randomized study; 96 patients)
  82. Tainter CR. An evidence-based approach to traumatic pain management in the emergency department. Emerg Med Prac. 2012;14(8):1-26. (Review)
  83. Walker KJ, McGrattan K, Aas-Eng K, et al. Ultrasound guidance for peripheral nerve blockade. Cochrane Database Syst Rev. 2009(4):CD006459. (Cochrane review; 18 trials, 1344 patients)
  84. Colman I, Brown MD, Innes GD, et al. Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials. BMJ. 2004;329(7479):1369-1373. (Meta-analysis; 13 trials, 655 patients)
  85. Friedman BW, Mulvey L, Esses D, et al. Metoclopramide for acute migraine: a dose-finding randomized clinical trial. Ann Emerg Med. 2011;57(5):475-482. (Prospective randomized study; 356 patients)
  86. Orr SL, Aube M, Becker WJ, et al. Canadian Headache Society systematic review and recommendations on the treatment of migraine pain in emergency settings. Cephalalgia. 2015;35(3):271-284. (Systematic review and meta-analysis; 44 studies)
  87. Kostic MA, Gutierrez FJ, Rieg TS, et al. A prospective, randomized trial of intravenous prochlorperazine versus subcutaneous sumatriptan in acute migraine therapy in the emergency department. Ann Emerg Med. 2010;56(1):1-6. (Prospective randomized; 68 patients)
  88. Coppola M, Yealy DM, Leibold RA. Randomized, placebo-controlled evaluation of prochlorperazine versus metoclopramide for emergency department treatment of migraine headache. Ann Emerg Med. 1995;26(5):541-546. (Prospective randomized; 75 patients)
  89. Friedman BW, Irizarry E, Solorzano C, et al. Randomized study of IV prochlorperazine plus diphenhydramine vs IV hydromorphone for migraine. Neurology. 2017;89(20):2075-2082. (Prospective randomized; 127 patients)
  90. Akpunonu BE, Mutgi AB, Federman DJ, et al. Subcutaneous sumatriptan for treatment of acute migraine in patients admitted to the emergency department: a multicenter study. Ann Emerg Med. 1995;25(4):464-469. (Prospective randomized; 136 patients)
  91. Friedman BW, Corbo J, Lipton RB, et al. A trial of metoclopramide vs sumatriptan for the emergency department treatment of migraines. Neurology. 2005;64(3):463-468. (Prospective randomized; 202 patients)
  92. Talabi S, Masoumi B, Azizkhani R, et al. Metoclopramide versus sumatriptan for treatment of migraine headache: a randomized clinical trial. J Res Med Sci. 2013;18(8):695-698. (Prospective randomized study; 124 patients)
  93. Taggart E, Doran S, Kokotillo A, et al. Ketorolac in the treatment of acute migraine: a systematic review. Headache. 2013;53(2):277-287. (Systematic review; 34 studies, 321 patients)
  94. Silberstein SD, Young WB, Mendizabal JE, et al. Acute migraine treatment with droperidol: a randomized, double-blind, placebo-controlled trial. Neurology. 2003;60(2):315-321. (Prospective randomized study; 331 patients)
  95. Weaver CS, Jones JB, Chisholm CD, et al. Droperidol vs prochlorperazine for the treatment of acute headache. J Emerg Med. 2004;26(2):145-150. (Prospective randomized study; 96 patients)
  96. Miner JR, Fish SJ, Smith SW, et al. Droperidol vs. prochlorperazine for benign headaches in the emergency department. Acad Emerg Med. 2001;8(9):873-879. (Prospective randomized study; 168 patients)
  97. Honkaniemi J, Liimatainen S, Rainesalo S, et al. Haloperidol in the acute treatment of migraine: a randomized, double-blind, placebo-controlled study. Headache. 2006;46(5):781-787. (Prospective randomized; 40 patients)
  98. Gaffigan ME, Bruner DI, Wason C, et al. A randomized controlled trial of intravenous haloperidol vs. intravenous metoclopramide for acute migraine therapy in the emergency department. J Emerg Med. 2015;49(3):326-334. (Prospective randomized controlled study; 64 patients)
  99. Nicolodi M, Sicuteri F. Exploration of NMDA receptors in migraine: therapeutic and theoretic implications. Int J Clin Pharmacol Res. 1995;15(5-6):181-189. (Prospective randomized study; 34 patients)
  100. Zitek T, Gates M, Pitotti C, et al. A comparison of headache treatment in the emergency department: prochlorperazine versus ketamine. Ann Emerg Med. 2018;71(3):369-377. (Prospective randomized study; 56 patients)
  101. Colman I, Friedman BW, Brown MD, et al. Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ. 2008;336(7657):1359-1361. (Review)
  102. Singh A, Alter HJ, Zaia B. Does the addition of dexamethasone to standard therapy for acute migraine headache decrease the incidence of recurrent headache for patients treated in the emergency department? A meta-analysis and systematic review of the literature. Acad Emerg Med. 2008;15(12):1223-1233. (Systematic review and meta-analysis; 7 trials, 742 patients)
  103. Afridi SK, Shields KG, Bhola R, et al. Greater occipital nerve injection in primary headache syndromes--prolonged effects from a single injection. Pain. 2006;122(1-2):126-129. (Prospective observational study; 110 patients)
  104. Blumenfeld A, Ashkenazi A, Napchan U, et al. Expert consensus recommendations for the performance of peripheral nerve blocks for headaches--a narrative review. Headache. 2013;53(3):437-446. (Expert consensus)
  105. Tang Y, Kang J, Zhang Y, et al. Influence of greater occipital nerve block on pain severity in migraine patients: a systematic review and meta-analysis. Am J Emerg Med. 2017;35(11):1750-1754. (Systematic review)
  106. Friedman BW, Mohamed S, Robbins MS, et al. A randomized, sham-controlled trial of bilateral greater occipital nerve blocks with bupivacaine for acute migraine patients refractory to standard emergency department treatment with metoclopramide. Headache. 2018;58(9):1427-1434. (Prospective randomized study; 28 patients)
  107. Allen SM, Mookadam F, Cha SS, et al. Greater occipital nerve block for acute treatment of migraine headache: a large retrospective cohort study. J Am Board Fam Med. 2018;31(2):211-218. (Retrospective cohort; 562 patients)
  108. Mellick LB, McIlrath ST, Mellick GA. Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 417 patients. Headache. 2006;46(9):1441-1449. (Retrospective study; 417 patients)
  109. Mellick LB, Pleasant MR. Do pediatric headaches respond to bilateral lower cervical paraspinous bupivacaine injections? Pediatr Emerg Care. 2010;26(3):192-196. (Retrospective study; 13 patients)
  110. Holdgate A, Pollock T. Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic. Cochrane Database Syst Rev. 2005(2):CD004137. (Cochrane review; 20 trials, 1613 patients)
  111. Afshar K, Jafari S, Marks AJ, et al. Nonsteroidal anti-inflammatory drugs (NSAIDs) and non-opioids for acute renal colic. Cochrane Database Syst Rev. 2015(6):CD006027. (Cochrane review; 50 studies, 5734 participants)
  112. Stein A, Ben Dov D, Finkel B. Single-dose intramuscular ketorolac versus diclofenac for pain management in renal colic. Am J Emerg Med. 1996;14:385-387. (Prospective randomized study; 57 patients)
  113. Cohen E, Hafner R, Rotenberg Z, et al. Comparison of ketorolac and diclofenac in the treatment of renal colic. Eur J Clin Pharmacol. 1998;54:455-458. (Prospective randomized study; 57 patients)
  114. Bektas F, Eken C, Karadeniz O, et al. Intravenous paracetamol or morphine for the treatment of renal colic: a randomized, placebo-controlled trial. Ann Emerg Med. 2009;54(4):568-574. (Prospective randomized study; 146 patients)
  115. Serinken M, Eken C, Turkcuer I, et al. Intravenous paracetamol versus morphine for renal colic in the emergency department: a randomised double-blind controlled trial. Emerg Med J. 2012;29(11):902-905. (Prospective randomized study; 73 patients)
  116. Masoumi K, Forouzan A, Asgari Darian A, et al. Comparison of clinical efficacy of intravenous acetaminophen with intravenous morphine in acute renal colic: a randomized, double-blind, controlled trial. Emerg Med Int. 2014;2014:571326. (Prospective randomized study; 108 patients)
  117. Azizkhani R, Pourafzali SM, Baloochestani E, et al. Comparing the analgesic effect of intravenous acetaminophen and morphine on patients with renal colic pain referring to the emergency department: a randomized controlled trial. J Res Med Sci. 2013;18(9):772-776. (Prospective randomized; 84 patients)
  118. Jalili M, Entezari P, Doosti-Irani A, et al. Desmopressin effectiveness in renal colic pain management: systematic review and meta-analysis. Am J Emerg Med. 2016;34(8):1535-1541. (Meta-analysis; 10 studies)
  119. Jalili M, Shirani F, Entezari P, et al. Desmopressin/indomethacin combination efficacy and safety in renal colic pain management: a randomized placebo controlled trial. Am J Emerg Med. 2018. (Prospective randomized study; 124 patients)
  120. Hollingsworth JM, Canales BK, Rogers MA, et al. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ. 2016;355:i6112. (Systematic review and meta-analysis; 55 randomized controlled trials)
  121. Ye Z, Zeng G, Yang H, et al. Efficacy and safety of tamsulosin in medical expulsive therapy for distal ureteral stones with renal colic: a multicenter, randomized, double-blind, placebo-controlled trial. Eur Urol. 2018;73(3):385-391. (Double-blind placebo-controlled study; 3296 patients in 30 centers)
  122. Meltzer AC, Burrows PK, Wolfson AB, et al. Effect of tamsulosin on passage of symptomatic ureteral stones: a randomized clinical trial. JAMA Intern Med. 2018;178(8):1051-1057. (Double-blind placebo-controlled clinical trial; 512 participants)
  123. Furyk JS, Chu K, Banks C, et al. Distal ureteric stones and tamsulosin: A double-blind, placebo-controlled, randomized, multicenter trial. Ann Emerg Med. 2016;67(1):86-95. (Randomized double-blind placebo-controlled multicenter trial; 403 patients)
  124. Pickard R, Starr K, MacLennan G, et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Lancet. 2015;386(9991):341-349. (Multicenter randomized placebo-controlled trial; 1167 participants)
  125. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. (Guideline)
  126. Krebs EE, Gravely A, Nugent S, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA. 2018;319(9):872-882. (Prospective randomized; 240 patients)
  127. Friedman BW, Irizarry E, Solorzano C, et al. Diazepam is no better than placebo when added to naproxen for acute low back pain. Ann Emerg Med. 2017;70(2):169-176. (Prospective randomized; 114 patients)
  128. Friedman BW, Cisewski D, Irizarry E, et al. A randomized, double-blind, placebo-controlled trial of naproxen with or without orphenadrine or methocarbamol for acute low back pain. Ann Emerg Med. 2018;71(3):348-356. (Prospective randomized study; 240 patients)
  129. Kocak AO, Ahiskalioglu A, Sengun E, et al. Comparison of intravenous NSAIDs and trigger point injection for low back pain in ED: a prospective randomized study. Am J Emerg Med. 2019. (Prospective randomized study; 54 patients)
  130. Saeidian SR, Pipelzadeh MR, Rasras S, et al. Effect of trigger point injection on lumbosacral radiculopathy source. Anesth Pain Med. 2014;4(4):e15500. (Prospective randomized study; 98 patients)
  131. Cruccu G, Truini A. A review of neuropathic pain: from guidelines to clinical practice. Pain Ther. 2017;6(Suppl 1):35-42. (Review)
  132. Hu J, Huang D, Li M, et al. Effects of a single dose of preoperative pregabalin and gabapentin for acute postoperative pain: a network meta-analysis of randomized controlled trials. J Pain Res. 2018;11:2633-2643. (Systematic review)
  133. Berry JD, Petersen KL. A single dose of gabapentin reduces acute pain and allodynia in patients with herpes zoster. Neurology. 2005;65(3):444-447. (Prospective randomized controlled trial)
  134. Wiffen PJ, Derry S, Bell RF, et al. Gabapentin for chronic neuropathic pain in adults. Cochrane Database Syst Rev. 2017;6:CD007938. (Cochrane review; 37 studies, 5914 participants)
  135. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Washington, DC: American Psychiatric Publishing; 2013. (Book)
  136. Schuckit MA. Treatment of opioid-use disorders. N Engl J Med. 2016;375(16):1596-1597. (Review)
  137. Quinlan J, Cox F. Acute pain management in patients with drug dependence syndrome. Pain Rep. 2017;2(4):e611. (Review)
  138. Duber HC, Barata IA, Cioe-Pena E, et al. Identification, management, and transition of care for patients with opioid use disorder in the emergency department. Ann Emerg Med. 2018;72(4):420-431. (Review)
  139. Hansen GR. The drug-seeking patient in the emergency room. Emerg Med Clin North Am. 2005;23(2):349-365. (Review)
  140. Inciardi JA, Surratt HL, Kurtz SP, et al. Mechanisms of prescription drug diversion among drug-involved club- and street-based populations. Pain Med. 2007;8(2):171-183. (Prospective interviews; 74 patients)
  141. MÜcke M, Phillips T, Radbruch L, et al. Cannabis-based medicines for chronic neuropathic pain in adults. Cochrane Database Syst Rev. 2018;3:CD012182. (Cochrane review; 16 studies, 1750 participants)
  142. Stockings E, Campbell G, Hall WD, et al. Cannabis and cannabinoids for the treatment of people with chronic noncancer pain conditions: a systematic review and meta-analysis of controlled and observational studies. Pain. 2018;159(10):1932-1954. (Systematic review; 104 studies, 9958 particpants)
  143. Stevens AJ, Higgins MD. A systematic review of the analgesic efficacy of cannabinoid medications in the management of acute pain. Acta Anaesthesiol Scand. 2017;61(3):268-280. (Systematic review; 7 studies, 611 patients)
  144. Patterson DR, Jensen MP, Wiechman SA, et al. Virtual reality hypnosis for pain associated with recovery from physical trauma. Int J Clin Exp Hypn. 2010;58(3):288-300. (Prospective randomized study; 21 patients)
  145. Jones T, Moore T, Choo J. The impact of virtual reality on chronic pain. PLoS One. 2016;11(12):e0167523. (Prospective study; 30 patients)
  146. Frey DP, Bauer ME, Bell CL, et al. Virtual Reality Analgesia in Labor: the VRAIL pilot study-a preliminary randomized controlled trial suggesting benefit of immersive virtual reality analgesia in unmedicated laboring women. Anesth Analg. 2018;128(6):e93-e96. (Prospective randomized study; 27 patients)
  147. Scapin S, Echevarria-Guanilo ME, Boeira Fuculo Junior PR, et al. Virtual reality in the treatment of burn patients: a systematic review. Burns. 2018;44(6):1403-1416. (Systematic review; 34 studies)
  148. Blaivas M, Adhikari S, Lander L. A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department. Acad Emerg Med. 2011;18(9):922-927. (Prospective randomized study; 42 patients)
  149. Castro E, Dent D. A comparison of transdermal over-the-counter lidocaine 3.6% menthol 1.25%, Rx lidocaine 5% and placebo for back pain and arthritis. Pain Manag. 2017;7(6):489-498. (Prospective randomized study; 87 patients)
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Publication Information
Authors

Abdulaziz Almehlisi, MBBS; Christopher Tainter, MD, RDMS

Peer Reviewed By

Al O. Giwa, LLB, MD, MBA, FACEP, FAAEM; Christopher Hahn, MD

Publication Date

November 1, 2019

CME Expiration Date

November 1, 2022

Pub Med ID: 31647862

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