Abstract
Purpose of Review
Relief of pain and discomfort is a critical component of the mission of every health care provider to reduce suffering. Pain management is of paramount importance in the provision of care at every level. This is an era of increasing patient expectations of care, yet also there exists an ongoing scourge of opiate abuse.
Recent Findings
ED visits for opioid overdoses rose 30% in all parts of the USA from July 2016 through September 2017. Deaths from narcotic overdose in the USA now exceed those from motor vehicle crashes. The concept of an “opiate-free” emergency department has been posited.
Summary
The emergency practitioner is presented with clinical and political challenges which did not exist in the past. This article elucidates current pharmacologic options regarding analgesia in the emergency setting, with some possible future options.
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References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Porter ME. What is value in health care? NEJM. 2010;363(26):2477–81.
Reuben DB, Tinetti ME. Goal-oriented patient care—an alternative health outcomes paradigm. NEJM. 2012;366(9):777–9.
Manary MP, Bounding W, Staelin R, Glickman SW. The patient experience and health outcomes. NEJM. 2013;368(3):201–3.
•• Todd KH. A review of current and emerging approaches to pain management in the emergency department. Pain Ther. 2017;6(2):193–202. Excellent overview of current non-narcotic analgesia trends.
Bellon T,. US state lawsuits against Purdue pharma over opioid epidemic mount. Reuters World, 2018.
• Centers for Disease Control and Prevention. MMWR. Vital signs: trends in emergency department visits for suspected opioid overdoses—United States July 2016–September 2017. 2018;67:1–8. Reinforces societal trends in opioid use and abuse.
Centers for Disease Control and Prevention. CDC Vital Signs. Opioid overdoses treated in emergency departments: identify opportunities for action. March 6, 2018 Available at www.cdc.gov/opioid-overdoses
ACEP 911 Weekly Update, April 27, 2018, May 11, 2018. Opioid bills move forward in house and senate.
Schwartz TM, Tai M, Babu KM, Merchant RC. Lack of association between Press Ganey emergency department patient satisfaction scores and emergency department administration of analgesic medications. Ann Emerg Med. 2014;64(5):469–81.
Joint Commission Accreditation of Healthcare Organizations. CAMH revised pain management standards. 2000 Available at http://www.jointcommission.org/standards_information/standards.aspx.
Zempsky WT, Cravero JP. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics. 2004;114:1348–56.
Mace SE, Brown LA, Francis L, Godwin SA, Hahn SA, Howard PK, et al. Clinical policy: critical issues in the sedation of pediatric patients in the emergency department. Ann Emerg Med. 2008;51(4):378–99.
Kennedy RM, Luhmann J, Zempsky WT. Clinical implications of unmanaged needle-insertion pain and distress in children. Pediatrics. 2008;122:S130–3.
Cantrill SV, Brown MD, Carlisle RJ, Delaney KA, Hays DP, Nelson LS, et al. Clinical policy: critical issues in the prescribing of opioids for adult patients in the emergency department. Ann Emerg Med. 2012;60:499–525.
Todd KH, Sloan EP, Chen C, Eder S, Wamstad K. Survey of pain etiology, management practices and patient satisfaction in two urban emergency departments. CJEM. 2002;4:252–6.
Smith RJ, Rhodes K, Paciotti B, Kelly S, Perrone J, Meisel ZF. Patient perspectives of acute pain management in the era of the opioid epidemic. Ann Emerg Med. 2015;66(3):246–52.
Zgierska A, Miller M, Rabago D. Patient satisfaction, prescription drug abuse, and potential unintended consequences. JAMA. 2012;307(13):1377–8.
Frantsve LME, Kerns RD. Patient-provider interactions in the management of chronic pain: current findings within the context of shared medical decision making. Pain Med. 2007;8(1):25–35.
Centers for Disease Control and Prevention (CDC). CDC Grand Rounds: prescription drug overdoses—a US epidemic. MMWR Morb Mortal Wkly Rep. 2012;61:10–3.
Fentanyl: the latest scourge. The Economist May 20, 2017: 13–14.
Hoppe JA, Nelson LS, Perrone J, Weiner SG, Rathlev NK, Sanchez LD, et al. Opioid prescribing in a cross section of US emergency departments. Ann Emerg Med. 2015;66(3):253–9.
Frieden TR, Houry D. Reducing the risks of relief- the CDC opioid-prescribing guideline. N Engl J Med. 2016;374(16):1501–4.
Asim A, Gomes T, Zheng H, et al. Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med. 2012;172:425–30.
CDC guideline for prescribing opioids for chronic pain—United States 2016. MMWR Recomm Rep 2016; 65 (RR-1): 1–49.
•• Tauben D. Nonopioid medications for pain. Phys Med Rehabil Clin N Am. 2015;26:219–48. State of the art discussion of treatment option for painful conditions.
Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, 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):872–82.
Szigethy E, Knisely M, Drossman D. Opioid misuse in gastroenterology and non-opioid management of abdominal pain. Nat Rev Gastroenterol Hepatol. 2018;15(3):168–80.
American Society of Anesthesiologists. Practice guidelines for acute pain management in the perioperative setting. Anesthesiology. 116(2):248–73.
Wick EC, Grant MC, Wu C. Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques. JAMA Surgery. 2017:E1–7.
Gobble RM, Hoang H. A meta-analysis of postoperative bleeding with the use of Toradol. Plast Reconstr Surg. 2012;130:66.
Drugs.com Ketorolac Injection.
Thomas DA, West M, Legler A, Maslin B, K. Kim R, Vadivelu N. Efficacy and safety of nonopioid analgesics in perioperative pain control. Curr Drug Saf. 2016;11:196–205.
Kaye AD, Cornett EM, Helander E, et al. An update on nonopioids. Anesthesiol Clin. 2017;35:e55–71.
Oyler DR, Parli SE, Bernard AC, Chang PK, Procter LD, Harned ME. Nonopioid management of acute pain associated with trauma: focus on pharmacologic options. J Trauma Acute Care Surg. 2015;79(3):475–83.
Bastiaens L, Galus J, Mazur C. Abuse of gabapentin is associated with opioid addiction. Psychiatr Q. 2016;87(4):763–7.
Cantrell FL, Mena O, Gary RD, McIntyre IM. An acute gabapentin fatality: a case report with postmortem concentrations. Int J Legal Med. 2015;129(4):771–5.
Gaertner J, Schiessl C. Cancer pain management: what’s new? Curr Pain Headache Rep. 2013;17:328.
Bell RF, Dahl JB, Moore RA, Kalso E. Perioperative ketamine for acute postoperative pain. Cochrane Database Syst Rev. 2006;1:CD0004603.
Elia N, Tramer MR. Ketamine and postoperative pain—a quantitative systematic review of randomized trials. Pain. 2005;113:61–70.
Motov SM, Nelson LS. Advanced concepts and controversies in emergency department pain management. Anesthesiol Clin. 2016;34:271–85.
Ducharme J. Non-opioid pain medications to consider for emergency department patients. ACEP Now 2015; 35(5).
De Oliveira GS Jr, Castro-Alves LJ, Khan JH, McCarthy RJ. Perioperative systemic magnesium to minimize postoperative pain: a meta-analysis of randomized controlled trials. Anesthesiology. 2013;119(1):178–90.
Barrevald A, Witte J, Chahal H, et al. Preventive analgesia by local anesthetics: the reduction of postoperative pain by peripheral nerve blocks and intravenous drugs. Anesth Analg. 2013;116:1141–61.
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;66:222–9.
Ferrini R, Paice JA. How to initiate and monitor infusional lidocaine for severe and/or neuropathic pain. J Support Oncol. 2004;2:90–4.
Tang C, Xia Z. Dexmedetomidine in perioperative acute pain management: a non-opioid adjuvant analgesic. J Pain Res. 2017;10:1899–904.
Malchow RJ, Black IH. The evolution of pain management in the critically ill trauma patient: emerging concepts from the global war on terrorism. Crit Care Med. 2008;36(Suppl 7):S346–57.
•• New painkiller studies: working toward non-addictive painkillers, posted in Prescription Drugs December 28, 2017. Available at www.promises.com/articles/prescription-drugs/new-painkiller-studies-woking-towarde. Accessed April 11, 2018. Discussion of future trends and development of alternative analgesics.
Ding H, Czoty PW, Kiguchi N, Cami-Kobeci G, Sukhtankar DD, Nader MA, et al. A novel orvinol analog, BU08028, as a safe opioid analgesic without abuse liability in primates. Proc Natl Acad Sci U S A. 2016;113(37):E5511–8.
Hall SM, LeBaron L, Ramos-Colon C, Qu C, Xie JY, Porreca F, et al. Discovery of stable non-opioid dynorphin A analogues interacting at the bradykinin receptor for the treatment of neuropathic pain. ACS Chem Neurosci. 2016;7(12):1746–52.
Rajagopalan P, Tracey H, Chen Z, Bandyopadhyaya A, Veeraraghavan S, Rajagopalan DR, et al. DDD-028: a potent potential non-opioid non-cannabinoid analgesic for neuropathic and inflammatory pain. Bioorg Med Chem Lett. 2014;24(14):3088–91.
Lopez-Canul M, Palazzo E, Dominguez-Lopez S, Luongo L, Lacoste B, Comai S, et al. Selective melatonin MT2 receptor ligands relieve neuropathic pain through modulation of brainstem descending antinociceptive pathways. Pain. 2015;156(2):305–17.
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Glauser, J., Money, S. Medical Management of Pain in the Emergency Setting Without Narcotics: Current Status and Future Options. Curr Emerg Hosp Med Rep 6, 134–140 (2018). https://doi.org/10.1007/s40138-018-0164-7
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DOI: https://doi.org/10.1007/s40138-018-0164-7