Emergency Department Pain Management: Beyond Opioids (Pharmacology CME and Pain Management CME)

Table of Contents

 

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?

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

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.

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Points and Pearls Excerpt

• Although assessment of pain is essential to its treatment, visual analog and numerical rating scales are problematic.
• Many pain specialists are moving to assessing pain with functional assessments. The Brief Pain Inventory Short Form (BPI-SF) has been found to be feasible for use in the ED.
• In the prehospital setting, ketamine has been used at 0.3 mg/kg for analgesia, with promising results when compared to fentanyl.
• Consider nonpharmacologic treatment of pain such as immobilization, splinting, orthopedic reduction, heat or ice, electrical nerve stimulation, deep breathing, music therapy, aromatherapy, guided imagery, verbal suggestion, and family support.

Most Important References

• 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) 
• 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) 
• 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
• 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)
• 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)
• 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) 
• 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)