Advertisement

The Evolving Landscape of Acute Pain Management in the Era of the Opioid Crisis

  • Ali Pourmand
  • Gregory Jasani
  • Courtney Shay
  • Maryann Mazer-Amirshahi
Hot Topics in Pain and Headache (N Rosen, Section Editor)
  • 385 Downloads
Part of the following topical collections:
  1. Topical Collection on Hot Topics in Pain and Headache

Abstract

Purpose of Review

The purpose of the study is to evaluate and analyze the role of both opioid and non-opioid analgesics in the emergency department (ED).

Recent Findings

Studies have shown that the implementation of opioid-prescribing policies in the ED has the potential to reduce the opioid addiction burden. Clinical studies point to inconsistencies in providers’ approach to pain treatment. In this review, we discuss specific aspects of opioid utilization and explore alternative non-opioid approaches to pain management.

Summary

Pain is the most common reason patients present to the ED. As such, emergency medicine (EM) providers must be well versed in treating pain. EM providers must be comfortable using a wide variety of analgesic medications. Opioid analgesics, while effective for some indications, are associated with significant adverse effects and abuse potential. EM providers should utilize opioid analgesics in a safe and rational manner in an effort to combat the opioid epidemic and to avoid therapeutic misadventures. EM providers should be aware of all of their therapeutic options, e.g., opioid and non-opioid, in order to provide effective analgesia for their patients, while avoiding adverse effects and minimizing the potential for misuse.

Keywords

Opioid Prescriptions Non-opioid pain medications NSAIDS 

Notes

Compliance with Ethical Standards

Conflict of Interest

Ali Pourmand, Gregory Jasani, Courtney Shay, and Maryann Mazer-Amirshahi declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Understanding the Epidemic, Drug overdose deaths in the United States continue to increase in 2015. https://www.cdc.gov/drugoverdose/epidemic/index.html; 2016 [accessed 11.08.17].
  2. 2.
    Chang H-Y, Daubresse M, Kruszewski SP, Alexander GC. Prevalence and treatment of pain in EDs in the United States, 2000 to 2010. Am J Emerg Med. 2014;32(5):421–31.CrossRefPubMedGoogle Scholar
  3. 3.
    Highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. https://www.samhsa.gov/data/sites/default/files/DAWN127/DAWN127/sr127-DAWN-highlights.pdf; 2011[accessed 11.08.17].
  4. 4.
    Poon SJ, Greenwood-Ericksen MB, Galicia-Castillo M, et al. The opioid prescription epidemic and the role of emergency medicine. Ann Emerg Med 2014;64(5):490–495.CrossRefPubMedGoogle Scholar
  5. 5.
    Institute of Medicine (U.S.). Committee on advancing pain research C. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. National Academies Press; 2011.Google Scholar
  6. 6.
    Mazer-Amirshahi M, Mullins PM, Rasooly I, van den Anker J, Pines JM. Rising opioid prescribing in adult U.S. emergency department visits: 2001-2010. Acad Emerg Med. 2014;21(3):236–43.CrossRefPubMedGoogle Scholar
  7. 7.
    •• JA H, Nelson LS, Perrone J, et al. Opioid prescribing in a cross section of US emergency departments. Ann Emerg Med. 2015;66(3):253–259.e1. A good example of analyzing the characteristics of patients and opioid prescriptions among patients visiting emergency department. CrossRefGoogle Scholar
  8. 8.
    Lyapustina T, Castillo R, Omaki E, Shields W, McDonald E, Rothman R, et al. The contribution of the emergency department to opioid pain reliever misuse and diversion: a critical review. Pain Pract. 2017;17:1097–104.  https://doi.org/10.1111/papr.12568.CrossRefPubMedGoogle Scholar
  9. 9.
    Liu Y, Logan JE, Paulozzi LJ, Zhang K, Jones CM. Potential misuse and inappropriate prescription practices involving opioid analgesics. Am J Manag Care. 2013;19(8):648–65.PubMedGoogle Scholar
  10. 10.
    Levy B, Paulozzi L, Mack KA, Jones CM. Trends in opioid analgesic–prescribing rates by specialty, U.S., 2007–2012. Am J Prev Med. 2015;49(3):409–13.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Lanser P, Gesell S. Pain management: the fifth vital sign. Healthc Benchmarks. 2001;8(6):68–70.PubMedGoogle Scholar
  12. 12.
    Pizzo PA, Clark NM. Alleviating suffering 101—pain relief in the United States. N Engl J Med. 2012;366(3):197–9.CrossRefPubMedGoogle Scholar
  13. 13.
    D’Onofrio G, O’Connor PG, Pantalon MV, Chawarski MC, Busch SH, Owens PH, et al. Emergency department–initiated buprenorphine/naloxone treatment for opioid dependence. JAMA. 2015;313(16):1636–44.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    • Osborn SR, Yu J, Williams B, Vasilyadis M, Blackmore CC. Changes in provider prescribing patterns after implementation of an emergency department prescription opioid policy. J Emerg Med. 2017;52(4):538–46. Very good source to provide insight regarding effectiveness of designing and implementing a prescription policy that could be associated with a significant reduction in opioid prescriptions. CrossRefPubMedGoogle Scholar
  15. 15.
    Beaudoin FL, Banerjee GN, Mello MJ. State-level and system-level opioid prescribing policies: the impact on provider practices and overdose deaths, a systematic review. J Opioid Manag. 2016;12(2):109–18.CrossRefPubMedGoogle Scholar
  16. 16.
    Burton JH, Miner J. Emergency sedation and pain management. New York, NY: Cambridge University Press; 2008. p. 49–53.CrossRefGoogle Scholar
  17. 17.
    Patanwala AE, Edwards CJ, Stolz L, Amini R, Desai A, Stolz U. Should morphine dosing be weight based for analgesia in the emergency department? J Opioid Manag. 2012;8:51–5.CrossRefPubMedGoogle Scholar
  18. 18.
    Bijur P, Kenny M, Gallagher E. Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients. Ann Emerg Med. 2005;46(4):362–7.CrossRefPubMedGoogle Scholar
  19. 19.
    Birnbaum A, Esses D, Bijur PE, Holden L, Gallagher EJ. Randomized double-blind placebo-controlled trial of two intravenous morphine dosages (0.10 mg/kg and 0.15 mg/kg) in emergency department patients with moderate to severe acute pain. Ann Emerg Med. 2007;49:445–53.CrossRefPubMedGoogle Scholar
  20. 20.
    Lvovschi V, Aubrun F, Bonnet P, Bouchara A, Bendahou M, Humbert B, et al. Intravenous morphine titration to treat severe pain in the ED. Am J Emerg Med. 2008;26:676–82.CrossRefPubMedGoogle Scholar
  21. 21.
    Birnbaum A, Schechter C, Tufaro V, Touger R, Gallagher EJ, Bijur P. Efficacy of patient-controlled analgesia for patients with acute abdominal pain in the emergency department: a randomized trial. Acad Emerg Med. 2012;19:370–7.CrossRefPubMedGoogle Scholar
  22. 22.
    Bijur P, Esses D, Chang A, Gallagher E. Dosing and titration of intravenous opioid analgesics administered to ED patients in acute severe pain. Am J Emerg Med. 2012;30:1241–4.CrossRefPubMedGoogle Scholar
  23. 23.
    Smith M, Wang Y, Cudnik M, Smith D, Pakiela J, Emerman C. The effectiveness and adverse events of morphine versus fentanyl on a physician-staffed helicopter. J Emerg Med. 2011;43:69–75.CrossRefGoogle Scholar
  24. 24.
    Patanwala A, Holmes K, Erstad B. Analgesic response to morphine in obese and morbidly obese patients in the emergency department. Emerg Med J. 2014;31:139–42.CrossRefPubMedGoogle Scholar
  25. 25.
    Puymirat E, Lamhaut L, Bonnet N, Aissaoui N, Henry P, Cayla G, et al. Correlates of pre-hospital morphine use in ST-elevation myocardial infarction patients and its association with in-hospital outcomes and long-term mortality: the FAST-MI (French Registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction) programme. Eur Heart J. 2015;10:1–9.Google Scholar
  26. 26.
    Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manag. 2004;28(5):497–504.CrossRefGoogle Scholar
  27. 27.
    Hagen N, Foley K, Cerbone D, Portenoy R, Inturissi C. Chronic nausea and morphine-6-glucuronide. J Pain Symptom Manag. 1991;6(3):125–8.CrossRefGoogle Scholar
  28. 28.
    Conway B, Fogarty D, Nelson W, Doherty C. Opiate toxicity in patients with renal failure. Br Med J. 2006;11:345–6.CrossRefGoogle Scholar
  29. 29.
    Wightman R, Perrone J, Portelli I, Nelson L. Likeability and abuse liability of commonly prescribed opioids. J Med Toxicol. 2012 Dec;8(4):335–40.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Jasani NB, O'Conner RE, Bouzoukis JK. Comparison of hydromorphone and meperidine for ureteral colic. Acad Emerg Med. 1994;1:539–43.CrossRefPubMedGoogle Scholar
  31. 31.
    Tanabe P, Artz N, Courtney D, Martinovich Z, Weiss K, Zvirbulis E, et al. Adult emergency department patients with sickle cell pain crisis: a learning collaborative model to improve analgesic management. Acad Emerg Med. 2010;19(4):430–8.CrossRefGoogle Scholar
  32. 32.
    Chang AK, Bijur PE, Campbell CM, Murphy MK, Gallagher EJ. Safety and efficacy of rapid titration using 1mg doses of intravenous hydromorphone in emergency department patients with acute severe pain: the “1+1” protocol. Ann Emerg Med. 2009;54:221–5.CrossRefPubMedGoogle Scholar
  33. 33.
    Chang AK, Bijur PE, Davitt M, Gallagher EJ. Randomized clinical trial comparing a patient-driven titration protocol of intravenous hydromorphone with traditional physician-driven management of emergency department patients with acute severe pain. Ann Emerg Med. 2009;54:561–7.CrossRefPubMedGoogle Scholar
  34. 34.
    Chang AK, Bijur PE, Napolitano A, Lupow J, Gallagher EJ. Two milligrams i.v. hydromorphone is efficacious for treating pain but is associated with oxygen desaturation. J Opioid Manag. 2009;5:75–80.CrossRefPubMedGoogle Scholar
  35. 35.
    DiGiusto M, Tarun B, David M, Derek F, Megan J, Joseph D. Patient-controlled analgesia in the pediatric population: morphine versus hydromorphone. J Pain Res. 2014;7:471–5.PubMedPubMedCentralGoogle Scholar
  36. 36.
    • Mazer-Amirshahi M, Motov S, Nelson L. Hydromorphone for acute pain: misconceptions, controversies, and risks. J Opioid Manag. 2018;14(1):61–17. This serves as a great review of how a potent opioid that routinely administer in acute clinical setting, has potential for misconceptions, controversies, and risks. CrossRefPubMedGoogle Scholar
  37. 37.
    Miner JR, Burton J. Pain management. In: Marx JA, Hockberger RS, Walls RM, Biros MH, editors. Rosen’s emergency medicine 1. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014. p. 31–49.Google Scholar
  38. 38.
    Curtis KM, Henriques HF, Fanciullo G, Reynolds CM, Suber F. A fentanyl-based pain management protocol provides early analgesia for adult trauma patients. J Trauma. 2007;63:819–26.CrossRefPubMedGoogle Scholar
  39. 39.
    Thomas SH, Benevelli W, Brown D, Wedel SK. Safety of fentanyl for analgesia in adults undergoing air medical transport from trauma scenes. Air Med J. 1996;15(2):57–9.CrossRefGoogle Scholar
  40. 40.
    Coruh B, Tonelli MR, Park DR. Fentanyl-induced chest wall rigidity. Chest. 2013;144(3):1083–4.CrossRefPubMedGoogle Scholar
  41. 41.
    Saunders M, Adelgais K, Nelson D. Use of intranasal fentanyl for the relief of pediatric orthopedic trauma pain. Acad Emerg Med. 2010;17(11):1155–61.CrossRefPubMedGoogle Scholar
  42. 42.
    Shear M, Adler J, Shewakramani S. Transbuccal fentanyl for rapid relief of orthopedic pain in the ED. Am J Emerg Med. 2010;28(8):847–52.CrossRefPubMedGoogle Scholar
  43. 43.
    Towheed TE, Hochberg MC, Judd MG, Wells G. Acetaminophen for osteoarthritis. The Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD004257.Google Scholar
  44. 44.
    Shen H, Sprott H, Aeschillmann A, Gay RE, Michel BA, Gay S. Analgesic action of acetaminophen in symptomatic osteoarthritis of the knee. Oxford. 2006;45:765–70.Google Scholar
  45. 45.
    Bannuru R, Schmid C, Kent D, Vaysbrot E, Wong J, McAlindon T. Comparative effectiveness of pharmacologic interventions for knee osteoarthritis: a systematic review and meta analysis. Ann Intern Med. 2015;162(1):46–54.CrossRefPubMedGoogle Scholar
  46. 46.
    Yoon E, Babar A, Choudhary M, Kutner M, Pyrsopoulos N. Acetaminophen-induced hepatotoxicity; a comprehensive update. J Clin Transl Hepatol. 2016;4(2):131–42.PubMedPubMedCentralGoogle Scholar
  47. 47.
    Craig M, Jeavons R, Probert J, Benger J. Randomised comparison of intravenous paracetamol and intravenous morphine for acute traumatic limb pain in the emergency department. Emerg Med J. 2012;29(1):37–9.CrossRefPubMedGoogle Scholar
  48. 48.
    Esmailian M, Moshiri R, Majid Z. Comparison of the analgesic effect of intravenous acetaminophen and morphine sulfate in rib fracture: a randomized double-blind clinical trial. Emergency. 2015;3(3):99–102.PubMedPubMedCentralGoogle Scholar
  49. 49.
    Macario A, Royal M. A literature review of randomized clinical trials of intravenous acetaminophen (paracetamol) for acute postoperative pain. Pain Pract. 2010;11(3):290–6.CrossRefPubMedGoogle Scholar
  50. 50.
    Mernis D, Mehmet TI, Guksum K, Sezer A, Sut N. Intravenous paracetamol reduced the use of opioids, extubation time, and opioid-related adverse effects after major surgery in intensive care unit. J Crit Care. 2010;25(3):458–62.CrossRefGoogle Scholar
  51. 51.
    Furyk J, Levas D, Close B, Laspina K, Fitzpatrick M, Robinson K, et al. Intravenous versus oral paracetamol for acute pain in adults in the emergency department setting: a prospective, double-blinded, double-dummy randomized controlled trial. Emerg Med J. 2018;35(3):179–84.CrossRefPubMedGoogle Scholar
  52. 52.
    Wright J, Price S, Watson W. NSAID use and efficacy in the emergency department: single doses of ibuprofen versus intramuscular ketorolac. Ann Pharmaco. 1994;28(3):309–12.CrossRefGoogle Scholar
  53. 53.
    Turturro M, Paris P, Seaberg D. Intramuscular ketorolac versus oral ibuprofen in acute musculoskeletal pain. Ann Emerg Med. 1995;26(2):117–20.CrossRefPubMedGoogle Scholar
  54. 54.
    Samcam I, Papa L. Acute pain management in the emergency department. In: Prostran M. Pain management. 1st ed. InTech Open. 2016.Google Scholar
  55. 55.
    Adebajo A. Non-steroidal anti-inflammatory drugs for the treatment of pain and immobility-associated osteoarthritis: consensus guidance for primary care. BMC Fam Pract. 2012;13:23.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Golzari SE, Soleimanpour H, Rahmani F, Zamani Mehr N, Safari S, Heshmat Y, et al. Therapeutic approaches for renal colic in the emergency department: a review article. Anesthesiol Pain Med. 2014;4(1):e16222.Google Scholar
  57. 57.
    Masso Gonzalex EL, Patrignani P, Taconelli S, Garcia Rodriguez LA. Variability among nonsteroidal antiinflammatory drugs in risk of upper gastrointestinal bleeding. Arthritis Rheum. 2010;62(6):1592–601.CrossRefGoogle Scholar
  58. 58.
    Rios A, Vargas-Robles H, Gamez-Mendez AM, Escalante B. Cyclooxygenase-2 and kidney failure. Prostag Oth Lipid Med. 2012;98:86–90.CrossRefGoogle Scholar
  59. 59.
    Green T, Gonzalez AA, Mitchell KD, Navar LG. The complex interplay between cyclooxygenase-2 ans angiotensin II in regulating kidney function. Curr Opin Nephrol Hy. 2012;21:7–14.CrossRefGoogle Scholar
  60. 60.
    Mukherjee D, Nissen S, Topol E. Risk of cardiovascular events associated with selective cox-2 inhibitors. JAMA. 2001;286(8):954–9.CrossRefPubMedGoogle Scholar
  61. 61.
    Jelinek G. Ketorolac versus morphine for severe pain. BMJ. 2000;321(7271):1236–7.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Safdar B, Degutis LC, Landry K, Vedere SR, Moscovitz HC, D’Onofrio G. Intravenous morphine versus ketorolac is superior to either drug alone for treatment of acute renal colic. Ann Emerg Med. 2006;48(2):173–81.CrossRefPubMedGoogle Scholar
  63. 63.
    van Tulder MW, Scholten RJ, Koes BW, Deyo RA. Non-steroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev. 2000;25(19):2501–13.Google Scholar
  64. 64.
    Friedman BW, Dym AA, Davitt M, Holden L, Solorzano C, Esses D, et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating low back pain: a randomized clinical trial. JAMA. 2015;314(15):1572–80.CrossRefPubMedGoogle Scholar
  65. 65.
    Thomas S. Management of pain in the emergency department. Emerg Med, vol. 2013, Article ID 583132, 19 pages, 2013.  https://doi.org/10.1155/2013/583132 CrossRefGoogle Scholar
  66. 66.
    Jennings P, Cameron P, Bernard S, Walker T, Jolley D, Fitzgerald M, et al. Morphine and ketamine is superior to morphine alone for out-of-hospital trauma analgesia; a randomized controlled trial. Ann Emerg Med. 2012;11:1–7.Google Scholar
  67. 67.
    Jennings P, Cameron P, Bernard S. Ketamine as an analgesic in the pre-hospital setting: a systematic review. Acat Anaesthiol Scand. 2011;55(6):638–43.CrossRefGoogle Scholar
  68. 68.
    Svenson J, Abernathy M. Ketamine for pre-hospital use: a new look at an old drug. Am J Emerg Med. 2007;25(8):977–80.CrossRefPubMedGoogle Scholar
  69. 69.
    Motov S, Rockoff B, Cohen V, Pushkar I, Likourezos A, McKay C, et al. Intravenous subdissociative-dose ketamine versus morphine for analgesia in the emergency department: a randomized controlled trial. Ann Emerg Med. 2015;66(3):222–9.CrossRefPubMedGoogle Scholar
  70. 70.
    Herring A, Ahern T. Emerging applications of low-dose ketamine for pain management in the ED. Am J Emerg Med. 2013;31(2):416–9.CrossRefPubMedGoogle Scholar
  71. 71.
    Thomas S. Management of pain in the emergency department. ISRN Emerg Med. 2013;2013:1–19.CrossRefGoogle Scholar
  72. 72.
    Pourmand A, Mazer-Amirshahi M, Royall C, Alhawas R, Shesser R. Low dose ketamine use in the emergency department, a new direction in pain management. Am J Emerg Med. 2017;35(6):918–21.CrossRefPubMedGoogle Scholar
  73. 73.
    Lee J, Jeon W, Park E. Adjunctive atropine versus metoclopramide: can we reduce ketamine-associated vomiting in young children? A prospective, randomized, open, controlled study. Acad Emerg Med. 2012;19:1128–33.CrossRefPubMedGoogle Scholar
  74. 74.
    Richards J, Rockford R. Low-dose ketamine analgesia: patient and physician experience in the ED. Am J Emerg Med. 2013;31(2):390–4.CrossRefPubMedGoogle Scholar
  75. 75.
    Sener S, Eken C, Schultz H, Serinken M, Ozsarac M. Ketamine with and without midazolam for emergency department sedation in adults: a randomized controlled trial. Ann Emerg Med. 2011;57(2):109–14.CrossRefPubMedGoogle Scholar
  76. 76.
    Bar-Joseph G, Guilburd Y, Tamir A, Guilburd J. Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension: clinical article. J Neurosurg. 2009;4(1):40–6.Google Scholar
  77. 77.
    Firouzian A, Alipour A, Rashidian Dezfouli H, Zamani Kiasari A, Gholipour Baradari A, Emami Zeydi A, et al. Does lidocaine as an adjuvant to morphine improve pain relief in patients presenting to the ED with acute renal colic? A double-blind, randomized controlled trial. Am J Emerg Med. 2016;34(3):443–8.CrossRefPubMedGoogle Scholar
  78. 78.
    Chang L, Raty S, Ortiz J, Bailard N, Mathew S. The emerging use of ketamine for anesthesia and sedation in traumatic brain injuries. CNS Neurosci Ther. 2013;19(6):390–5.CrossRefPubMedPubMedCentralGoogle Scholar
  79. 79.
    Soleimanpour H, Hassanzadeh K, Vaezi H, Golzari SE, et al. Effectiveness of intravenous lidocaine versus intravenous morphine for patients with renal colic in the emergency department. BMC Urol. 2012;4(12):13.CrossRefGoogle Scholar
  80. 80.
    Tanen DA, Shimada M, Danish DC, Santos FD, Makela M, Riffenburgh RH. Intravenous lidocaine for the emergency department treatment of acute radicular low back pain, a randomized controlled trial. J Emerg Med. 2014;47(1):119–24.CrossRefPubMedGoogle Scholar
  81. 81.
    Wiffen PJ, Derry S, Bell RF, Rice ASC, Tölle TR, Phillips T, Moore RA. Gabapentin for chronic neuropathic pain in adults. Cochrane Database of Syst Rev 2017, Issue 6. Art. No.: CD007938.  https://doi.org/10.1002/14651858.CD007938.pub4
  82. 82.
    Smith RV, Lofwall MR, Havens JR. Abuse and diversion of gabapentin among nonmedical prescription opioid users in Appalachian Kentucky. Am J Psychiatry. 2015;172:487–8.CrossRefPubMedPubMedCentralGoogle Scholar
  83. 83.
    Smith R, Havens J, Walsh S. Gabapentin misuse, abuse, and diversion: a systematic review. Addiction. 2016;111(7):1160–74.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Ali Pourmand
    • 1
  • Gregory Jasani
    • 1
  • Courtney Shay
    • 1
  • Maryann Mazer-Amirshahi
    • 2
    • 3
  1. 1.Department of Emergency Medicine, Medical CenterThe George Washington UniversityWashington, DCUSA
  2. 2.Department of Emergency MedicineMedStar Washington Hospital CenterWashington, DCUSA
  3. 3.Georgetown University School of MedicineWashington, DCUSA

Personalised recommendations