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?
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Abstract
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Case Presentations
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Introduction
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Critical Appraisal of the Literature
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History of the Opioid Epidemic
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Pathophysiology
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Prehospital Care
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Emergency Department Evaluation
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Treatment
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Nonpharmacologic Pain Management
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Systemic Analgesia
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Nonsteroidal Anti-Inflammatory Drugs
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Gastrointestinal Effects of NSAIDs
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Renal Effects of NSAIDs
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Cardiac Effects of NSAIDs
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Orthopedic Effects of NSAIDs
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Safety of NSAIDs
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Topical NSAIDs
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Acetaminophen
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Dissociatives
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Alpha-2 Agonists
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Butyrophenones
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Systemic Local Anesthetics
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Regional Anesthesia
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Agents for Regional Anesthesia
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Topical Anesthesia
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Local Infiltration
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Regional Nerve Blocks
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Special Circumstances
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Headache
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Metoclopramide
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Prochlorperazine
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Sumatriptan
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Ketorolac
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Haloperidol and Droperidol
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Ketamine
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Dexamethasone
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Peripheral Nerve Blocks
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Lower Cervical Paraspinous Injection
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Recommendations for Headache Pain Management
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Renal Colic
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NSAIDs
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Acetaminophen
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Desmopressin
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Alpha-Adrenergic Receptor Blockers
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Recommendations for Renal Colic Pain
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Low Back Pain
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Benzodiazepines/Muscle Relaxants
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Trigger Point Injections
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Neuropathic Pain
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Managing Pain in Patients With Opioid-Use Disorder
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Controversies and Cutting Edge
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Cannabis and Cannabinoids
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Virtual Reality
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Time- and Cost-Effective Strategies
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Disposition
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Summary
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Risk Management Pitfalls for Nonopioid Pain Management
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Case Conclusions
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Clinical Pathway for Nonopioid Emergency Department Management of Pain
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Tables and Figures
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Table 1. Tools to Assess Pain and its Interference in Functional Capacities
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Table 2. Nonopioid Analgesic Agents
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Table 3. Gastrointestinal Risk Versus Cardiovascular Risk for NSAID Use
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Table 4. Selected Topical and Local Anesthetic Agents
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Table 5. Nerves and Anatomical Areas Amenable to Regional Nerve Blocks
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Figure 1. Opioid Overdose Deaths, 1999-2016
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Figure 2. Pathophysiology of Pain
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Figure 3. Hematoma Block
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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 1. Tools to Assess Pain and its Interference in Functional Capacities |
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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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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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Cruccu G, Truini A. A review of neuropathic pain: from guidelines to clinical practice. Pain Ther. 2017;6(Suppl 1):35-42. (Review)
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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)
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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)
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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)
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American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Washington, DC: American Psychiatric Publishing; 2013. (Book)
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Schuckit MA. Treatment of opioid-use disorders. N Engl J Med. 2016;375(16):1596-1597. (Review)
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Quinlan J, Cox F. Acute pain management in patients with drug dependence syndrome. Pain Rep. 2017;2(4):e611. (Review)
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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)
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Hansen GR. The drug-seeking patient in the emergency room. Emerg Med Clin North Am. 2005;23(2):349-365. (Review)
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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)
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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)
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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)
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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)
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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)
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Jones T, Moore T, Choo J. The impact of virtual reality on chronic pain. PLoS One. 2016;11(12):e0167523. (Prospective study; 30 patients)
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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)
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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)
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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)
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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)
Points and Pearls Excerpt
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Although assessment of pain is essential to its treatment, visual analog and numerical rating scales are problematic.
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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.
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In the prehospital setting, ketamine has been used at 0.3 mg/kg for analgesia, with promising results when compared to fentanyl.
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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
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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)
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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)
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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
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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)
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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)
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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)
To Read The Companion Article:
To Read The Companion Article:
To Read The Companion Article:
The PAINAD scale is used to assess pain in patients with dementia. The CPOT rates pain in critically ill patients by using clinical observations. The COWS is used to quantify the severity of opiate withdrawal.
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Pain Assessment in Advanced Dementia (PAINAD) Scale
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Critical-Care Pain Observation Tool (CPOT)
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Clinical Opiate Withdrawal Scale (COWS)
Pain Assessment in Advanced Dementia (PAINAD) Scale
Introduction
The PAINAD scale is used to assess pain in patients with dementia.
Points & Pearls
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The Pain Assessment in Advanced Dementia (PAINAD) scale is a reliable pain assessment tool for patients with advanced dementia. It can be used in both verbal and nonverbal patients.
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While the tool produces a score of 0 to 10 points, there is no definitive evidence that scores correlate with self-reported gradations of pain, as the original study defines only 0 (“no pain”) and 10 (“severe pain”). Caution should be used when titrating analgesic doses based on the PAINAD score.
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The PAINAD scale is valid in patients with levels of cognitive impairment ranging from mild to severe. It may also be useful in elderly patients who are reluctant to report pain, as it is more objective than self-reporting.
Why and When to Use, and Next Steps
Why to Use
It is difficult to assess pain in patients with advanced dementia; the use of a validated pain scale can help with such assessments.
When to Use
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Use the PAINAD scale for patients with advanced dementia who may be in pain.
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The PAINAD scale is particularly useful in aphasic patients or patients who cannot otherwise report the degree of pain.
Next Steps
As with pain management in general, pain in patients with advanced dementia should be assessed serially, and analgesic doses should be titrated accordingly.
Calculator Review Authors
Randy Goldberg, MD, MPH, FACP
Division of Internal Medicine, New York Medical
College; Westchester Medical Center, Valhalla, NY
Critical Actions
Analgesic medications should be used judiciously in patients with dementia, guided by the goals of care expressed by the patient or the patient’s proxy or surrogate.
Evidence Appraisal
The PAINAD scale was created by Warden et al (2003) in a study that observed 19 patients in an inpatient dementia special care unit at a Veterans Administration Medical Center. Each patient was assessed and scored by the principal investigator and 2 other raters who were drawn from a pool of 6 raters. Adequate levels of interrater reliability were found between each dyad. The PAINAD scale correlated well with the Discomfort Scale–Dementia of Alzheimer Type, and there was a statistically significant decrease in PAINAD scores after administration of analgesics.
The PAINAD scale was validated in a study of 25 elderly patients who were hospitalized for surgical repair of hip fractures (DeWaters 2008). Twelve of the patients were cognitively impaired and 13 were cognitively intact. The PAINAD scale was positively correlated with a self-reported pain scale, demonstrating concurrent validity, and PAINAD scores were higher when patients were likely to experience pain than when unlikely, demonstrating discriminant validity.
Mosele et al (2012) prospectively validated the PAINAD scale using evaluations of 600 patients who were admitted consecutively to the acute geriatric section at the University of Padua in Italy. The PAINAD scale was shown to be internally reliable and had better concurrent validity and interrater reliability than a self-reported numerical rating scale.
Calculator Creator
Victoria Warden, RN
References
Original/Primary Reference
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Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc. 2003;4(1):9-15.
Validation References
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Cohen-Mansfield J, Lipson S. The utility of pain assessment for analgesic use in persons with dementia. Pain. 2008;134(1-2):16-23.
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Hutchison RW, Tucker WF, Kim S, et al. Evaluation of a behavioral assessment tool for the individual unable to self-report pain. Am J Hosp Palliat Care. 2006;23(4):328-331.
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DeWaters T, Faut-Callahan M, McCann JJ, et al. Comparison of self-reported pain and the PAINAD scale in hospitalized cognitively impaired and intact older adults after hip fracture surgery. Orthop Nurs. 2008;27(1):21-28.
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Mosele M, Inelmen EM, Toffanello ED, et al. Psychometric properties of the pain assessment in advanced dementia scale compared to self assessment of pain in elderly patients. Dement Geriatr Cogn Disord. 2012;34(1):38-43.
Critical-Care Pain Observation Tool (CPOT)
Introduction
The CPOT rates pain in critically ill patients by using clinical observations.
Points & Pearls
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The gold standard of pain assessment is the patient’s self-report of pain. The Critical-Care Pain Observation Tool (CPOT) was designed to assess the pain of critically ill patients who are incapable of reporting their pain.
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The CPOT was created using retrospective reviews of common pain characteristics and was validated by intensive care unit (ICU) nurses and physicians.
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The original CPOT study included cardiac patients who were relatively healthy. The study used only 2 data collectors to perform the analysis. A subsequent evaluation included only 33 of 105 patients.
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CPOT scores were higher when patients were conscious and intubated than when unconscious or extubated, which may be due to endotracheal tube discomfort or positive pressure causing incision site pain.
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CPOT scores were similar for both unconscious and conscious extubated patients, which may be due to lingering anesthesia or pain resolution resulting from extubation.
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Further analyses have validated the CPOT score in multiple postsurgical and medical ICU settings.
Why and When to Use, Next Steps and Suggested Management
Why to Use
It is estimated that up to 71% of patients in the ICU experience untreated pain (Gélinas 2007). The Society of Intensive Care Medicine recommends routine monitoring of pain in ICU patients. Treatment of pain is associated with fewer days on mechanical ventilation, fewer infections, and increased patient satisfaction.
The CPOT uses objective findings to rate the pain of patients who are unable to report pain levels themselves. The CPOT has good interrater reliability in multiple studies and high sensitivity when patients are in pain.
When to Use
The CPOT can be used to rate pain in intubated or sedated patients by observing facial expressions, muscle tension, and movement, along with compliance with ventilated breaths for intubated patients or vocalized pain for nonintubated patients.
Next Steps
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For patients with a CPOT score ≤ 2, it is likely that there is minimal to no pain present. Re-evaluation should be considered, as appropriate.
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For patients with a CPOT score > 2, there is an unacceptable level of pain. Further or alternative analgesia and sedation should be considered.
Abbreviations: ICU, intensive care unit.
Calculator Review Authors
Benjamin Slovis, MD
Department of Emergency Medicine, Thomas Jefferson
University Hospital, Philadelphia, PA
Critical Action
Regular re-evaluation of a patient’s pain is crucial to appropriate pain management.
Evidence Appraisal
Elements of the CPOT were developed using a chart review of 52 critically ill patients, along with focus groups of nurses and physicians (Gélinas 2004). The relevance of inclusion criteria was validated with 4 physicians and 13 critical care nurses using a Likert scale, with content validity indices of 0.88 to 1.0 (Gélinas 2006). The validation study included a cohort of 105 patients, who were each tested 3 times during 3 periods, for a total of 9 tests. The tests were performed 1 minute before, during, and 1 minute after a positioning procedure. Exclusion criteria included heart transplant, thoracic aortic aneurysm repair, medical management of chronic pain, ejection fraction < 25%, psychiatric illness or neurologic problems, alcohol or drug dependence, use of postsurgical neuromuscular blockers, and surgical complications (eg, hemorrhage, delirium). Interrater reliability was high (kappa = 0.62-0.88) for all testing periods except for the fourth test (kappa = 0.52).
In all 3 testing phases, there was a statistically significant increase in CPOT score during positioning when compared with CPOT score before positioning. During the second testing period, intubated patients who reported pain had higher CPOT scores than those who reported no pain. During the final testing period, CPOT scores cor-related with reported pain intensity scores.
A post hoc analysis showed a sensitivity and specificity of 86% and 78%, respectively, during positioning (Gélinas 2009). Sensitivity was 83% before positioning and 63% after positioning, and specificity was 83% and 97%, respectively. A cutoff CPOT score of > 2 was established for nociceptive exposure. Additional validations include the following:
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A study of nurses’ evaluations of CPOT found that 72.7% of the respondents would recommend the tool for routine use and 78% found it easy to use (Gélinas 2010).
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A Spanish study found average CPOT scores prior to, during, and after positioning to be 0.27, 1.93, and 0.10 respectively, with kappa = 0.79 (Vázquez 2011).
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A neurosurgical ICU study demonstrated significantly higher scores for patients who reported pain during positioning. Area under the curve analysis showed good discrimination (0.864, P < .001 [95% confidence interval, 0.76-0.97]) (Echegaray-Benites 2014).
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A Dutch study comparing the CPOT to the Behavioral Pain Scale found an intraclass correlation coefficient of 0.6 to 0.81. The Behavioral Pain Scale had a significant score increase during nonpainful events, while the CPOT did not (Rijkenberg 2015).
Calculator Creator
Céline Gélinas, RN, PhD
References
Original/Primary Reference
Validation References
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Gélinas C, Harel F, Fillion L, et al. Sensitivity and specificity of the critical-care pain observation tool for the detection of pain in intubated adults after cardiac surgery. J Pain Symptom Manage. 2009;37(1):58-67.
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Gélinas C. Nurses’ evaluations of the feasibility and the clinical utility of the Critical-Care Pain Observation Tool. Pain Manag Nurs. 2010;11(2):115-125.
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Vázquez M, Pardavila MI, Lucia M, et al. Pain assessment in turning procedures for patients with invasive mechanical ventilation. Nurs Crit Care. 2011;16(4):178-185.
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Echegaray-Benites C, Kapoustina O, Gélinas C. Validation of the use of the Critical-Care Pain Observation Tool (CPOT) with brain surgery patients in the neurosurgical intensive care unit. Intensive Crit Care Nurs. 2014;30(5):257-265.
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Rijkenberg S, Stilma W, Endeman H, et al. Pain measurement in mechanically ventilated critically ill patients: Behavioral Pain Scale versus Critical-Care Pain Observation Tool. J Crit Care. 2015;30(1):167-172.
Clinical Opiate Withdrawal Scale (COWS)
Introduction
The COWS is used to quantify the severity of opiate withdrawal.
Points & Pearls
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While commonly used prior to buprenorphine or buprenorphine/naloxone induction, the Clinical Opiate Withdrawal Scale (COWS) can also be useful in a variety of medical office, clinic, and hospital settings. For example, it may be used in the assessment of acute opioid withdrawal during an opioid detoxification program, for methadone maintenance treatment, or for the treatment of chronic pain.
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The scale is designed to be completed by a clinician in < 2 minutes.
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Additional credentialing by the Center for Substance Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Services Administration is required to prescribe buprenorphine and buprenorphine/naloxone in the context of opioid addiction treatment.
Why and When to Use
Why to Use
The COWS combines subjective and objective components, limiting the possibility of feigned responses. It can be serially administered to track changes in the severity of opioid withdrawal symptoms over time or in response to treatment.
When to Use
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The COWS may be used in both inpatient and outpatient settings, including:
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During detoxification, for the general monitoring of opioid withdrawal during opioid detox.
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During pain treatment, for patients who are receiving opioids for the treatment of acute or chronic pain and who may show subtle signs of opioid withdrawal.
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In the emergency department and other settings for patients who request methadone for opioid withdrawal symptoms, when enrollment in methadone maintenance treatment has not been verified.
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The COWS is most commonly used in buprenorphine induction and is recommended specifically for this use.
Calculator Review Authors
Jonathan Avery, MD
Department of Psychiatry, Weill Cornell Medicine
New York, NY
Katherine E. Taylor, MD
Department of Psychiatry, New York University-Langone
Medical Center, New York, NY
Critical Action
Clinicians should always consider the possibility of comorbid withdrawal conditions from alcohol, benzodiazepines, or sedative-hypnotics, which may be life-threatening alone or in combination.
Advice
Prior to buprenorphine induction, patients should already be in moderate to severe opioid withdrawal (equivalent to a COWS score ≥ 8), as buprenorphine is a partial opioid agonist that can precipitate florid opioid withdrawal if administered to a physically dependent patient. Clinicians should be aware of this important criterion in order to prevent patients from experiencing precipitated withdrawal, which is a rapid and intense onset of withdrawal symptoms initiated by the medication. Self-reported “time since last opioid use” is not reliable because patients are not always accurate in reporting their last use, and metabolism varies from patient to patient.
Evidence Appraisal
The COWS was first published in a training manual for buprenorphine treatment (Wesson 2003). The scale consists of an 11-item rating system, designed to be completed within 2 minutes by a trained observer, to track opioid withdrawal (as dif-ferentiated from opioid toxicity) using serial assessments. It was designed to be administered quickly and to improve on existing assessment tools.
Tompkins et al (2009) validated the COWS in comparison to the validated Clinical Institute Narcotic Assessment scale. The study used a double-blind randomized design to compare opioid withdrawal symptoms for intramuscularly administered naloxone versus placebo in 46 patients with opioid dependency. The COWS and Clinical Institute Narcotic Assessment scores were well correlated during the naloxone challenge session, with a Pearson correlation coefficient of 0.85 (P < .001), while the placebo was not associated with any significant elevation in either score. Additional evidence of concurrent validity was provided by comparing COWS with the self-reported visual analogue scale; COWS scores correlated well with peak visual analogue scale scores of bad drug effect (r = 0.57, P < .001) and feeling sick (r = 0.57, P < .001). Cronbach’s alpha for the COWS was 0.78, indicating good internal consistency.
Calculator Creator
Donald R. Wesson, MD
References
Original/Primary Reference
Validation References
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