Emergency Department Pain Management: Beyond Opioids

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)