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.
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…
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.”
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.
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.
|Table 1. Tools to Assess Pain and its Interference in Functional Capacities|
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.
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
As with pain management in general, pain in patients with advanced dementia should be assessed serially, and analgesic doses should be titrated accordingly.
Randy Goldberg, MD, MPH, FACP
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.
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.
Victoria Warden, RN
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.
Abbreviations: ICU, intensive care unit.
Benjamin Slovis, MD
Regular re-evaluation of a patient’s pain is crucial to appropriate pain management.
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:
Céline Gélinas, RN, PhD
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
Jonathan Avery, MD
Katherine E. Taylor, MD
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.
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.
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.
Donald R. Wesson, MD
Abdulaziz Almehlisi, MBBS; Christopher Tainter, MD, RDMS
Al O. Giwa, LLB, MD, MBA, FACEP, FAAEM; Christopher Hahn, MD
November 1, 2019
November 30, 2022
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Pharmacology CME and 4 Pain Management CME credits
Date of Original Release: November 1, 2019. Date of most recent review: October 10, 2019. Termination date: November 1, 2022.
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AAFP Accreditation: This Enduring Material activity, Emergency Medicine Practice, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Term of approval begins 07/01/2019. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Approved for 4 AAFP Prescribed credits.
AOA Accreditation: Emergency Medicine Practice is eligible for 4 Category 2-A or 2-B credit hours per issue by the American Osteopathic Association.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Pharmacology CME and 4 Pain Management CME credits.
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