The Evolving Landscape of Acute Pain Management in the Era of the Opioid Crisis
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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).
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.
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.
KeywordsOpioid Prescriptions Non-opioid pain medications NSAIDS
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.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 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].
- 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].
- 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
- 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
- 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
- 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
- 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.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
- 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.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
- 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
- 54.Samcam I, Papa L. Acute pain management in the emergency department. In: Prostran M. Pain management. 1st ed. InTech Open. 2016.Google Scholar
- 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
- 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
- 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
- 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.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
- 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