Advertisement

The Treatment of Acute Pain in the Emergency Department: A White Paper Position Statement Prepared for the American Academy of Emergency Medicine

      Abstract

      Background

      Pain is one of the most common reasons patients present to the emergency department (ED). Emergency physicians should be aware of the numerous opioid and nonopioid alternatives available for the treatment of pain.

      Objectives

      To provide expert consensus guidelines for the safe and effective treatment of acute pain in the ED.

      Methods

      Multiple independent literature searches using PubMed were performed regarding treatment of acute pain. A multidisciplinary panel of experts in Pharmacology and Emergency Medicine reviewed and discussed the literature to develop consensus guidelines.

      Recommendations

      The guidelines provide resources for the safe use of opioids in the ED as well as pharmacological and nonpharmacological alternatives to opioid analgesia. Care should be tailored to the patient based on their specific acute painful condition and underlying risk factors and comorbidities.

      Conclusions

      Analgesia in the ED should be provided in the most safe and judicious manner, with the goals of relieving acute pain while decreasing the risk of complications and opioid dependence.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Cordell W.H.
        • Keene K.K.
        • Giles B.K.
        • et al.
        The high prevalence of pain in emergency medical care.
        Am J Emerg Med. 2012; 20: 165-169
        • Motov S.M.
        • Nelson L.S.
        Advanced concepts and controversies in emergency department pain management.
        Anesthesiol Clin. 2016; 34: 271-285
        • Morone N.E.
        • Weiner D.K.
        Pain as the fifth vital sign: exposing the vital need for pain education.
        Clin Ther. 2013; 35: 1728-1732
        • Dart R.C.
        • Surratt H.L.
        • Cicero T.J.
        • et al.
        Trends in opioid analgesic abuse and mortality in the United States.
        N Engl J Med. 2015; 372: 241-248
        • Lev R.
        • Lee O.
        • Petro S.
        • et al.
        Who is prescribing controlled medications to patients who die of prescription drug abuse?.
        Am J Emerg Med. 2016; 34: 30-35
        • Kelly S.
        • Johnson G.T.
        • Harbison R.D.
        “Pressured to prescribe” The impact of economic and regulatory factors on South-Eastern ED physicians when managing the drug seeking patient.
        J Emerg Trauma Shock. 2016; 9: 58-63
        • Rudd R.A.
        • Seth P.A.
        • David F.
        • Scholl L.
        Increases in drug and opioid-involved overdose deaths – United States, 2010–2015.
        MMWR Morb Mortal Wkly Rep. 2016; 65: 1445-1452
        • Warner M.
        • Chen L.H.
        • Makuc D.M.
        • Anderson R.N.
        • Miniño A.M.
        Drug poisoning deaths in the United States, 1980–2008.
        NCHS Data Brief. 2011; : 1-8
        • Ong C.K.
        • Seymour R.A.
        • Lirk P.
        • et al.
        Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain.
        Anesth Analg. 2010; 110: 1170-1179
        • Turkcuer I.
        • Serinken M.
        • Eken C.
        • et al.
        Intravenous paracetamol versus dexketoprofen in acute migraine attack in the emergency department: a randomised clinical trial.
        Emerg Med J. 2014; 31: 182-185
        • Craig M.
        • Jeavons R.
        • Probert J.
        • et al.
        Randomised comparison of intravenous paracetamol and intravenous morphine for acute traumatic limb pain in the emergency department.
        Emerg Med J. 2012; 29: 37-39
      1. Motov S, Strayer R, Hayes B, et al. AAEM White Paper on acute pain management in the emergency department. American Academy of Emergency Medicine. Available at: http://www.aaem.org/em-resources/position-statements/2017/pain-mgmt-in-ed. Accessed December 1, 2017.

        • Barnett M.L.
        • Olenski A.R.
        • Jena A.B.
        Opioid-prescribing patterns of emergency physicians and risk of long-term use.
        N Engl J Med. 2017; 376: 663-673
        • Castellsague J.
        • Riera-Guardia N.
        • Calingaert B.
        • et al.
        Individual NSAIDs and upper gastrointestinal complications: a systematic review and meta-analysis of observational studies (the SOS project).
        Drug Saf. 2012; 35: 1127-1146
        • Wright J.M.
        • Price S.D.
        • Watson W.A.
        NSAID use and efficacy in the emergency department: single doses of oral ibuprofen versus intramuscular ketorolac.
        Ann Pharmacother. 1994; 28: 309-312
        • Catapano M.S.
        The analgesic efficacy of ketorolac for acute pain [review].
        J Emerg Med. 1996; 14: 67-75
        • Derry S.
        • Moore R.A.
        • Gaskell H.
        • McIntyre M.
        • Wiffen P.J.
        Topical NSAIDs for acute musculoskeletal pain in adults.
        Cochrane Database Syst Rev. 2015; : CD007402
        • Derry S.
        • Conaghan P.
        • Da Silva J.A.
        • Wiffen P.J.
        • Moore R.A.
        Topical NSAIDs for chronic musculoskeletal pain in adults.
        Cochrane Database Syst Rev. 2016; : CD007400
        • McCarberg B.
        • D'Arcy Y.
        Options in topical therapies in the management of patients with acute pain.
        Postgrad Med. 2013; 125: 19-24
        • Affaitati G.
        • Fabrizio A.
        • Savini A.
        • et al.
        A randomized, controlled study comparing a lidocaine patch, a placebo patch, and anesthetic injection for treatment of trigger points in patients with myofascial pain syndrome: evaluation of pain and somatic pain thresholds.
        Clin Ther. 2009; 31: 705-720
        • Argoff C.E.
        • Galer B.S.
        • Jensen M.P.
        • Oleka N.
        • Gammaitoni A.R.
        Effectiveness of the lidocaine patch 5% on pain qualities in three chronic pain states: assessment with the Neuropathic Pain Scale.
        Curr Med Res Opin. 2004; 20: S21-S28
        • Yeh Y.C.
        • Reddy P.
        Clinical and economic evidence for intravenous acetaminophen.
        Pharmacotherapy. 2012; 32: 559-579
        • Ritcey B.
        • Pageau P.
        • Woo M.Y.
        • Perry J.J.
        Regional nerve blocks for hip and femoral neck fractures in the emergency department: a systematic review.
        CJEM. 2016; 18: 37-47
        • Motov S.
        • Rockoff B.
        • Cohen V.
        • et al.
        Intravenous subdissociative-dose ketamine versus morphine for analgesia in the emergency department: a randomized controlled trial.
        Ann Emerg Med. 2015; 66: 222-229
        • Beaudoin F.L.
        • Lin C.
        • Guan W.
        • et al.
        Low-dose ketamine improves pain relief in patients receiving intravenous opioids for acute pain in the emergency department: results of a randomized, double-blind, clinical trial.
        Acad Emerg Med. 2014; 21: 1193-1202
        • Goltser A.
        • Soleyman-Zomalan E.
        • Kresch F.
        • Motov F.
        Short (low-dose) ketamine infusion for managing acute pain in the ED: case-report series.
        Am J Emerg Med. 2015; 33: 601.e5-601.e7
        • Motov S.
        • Mai M.
        • Pushkar I.
        • et al.
        A prospective randomized, double-dummy trial comparing IV push low dose ketamine to short infusion of low dose ketamine for treatment pain in the ED.
        Am J Emerg Med. 2017; 35: 1095-1100
        • Sin B.
        • Tatunchak T.
        • Paryavi M.
        • Olivo M.
        • et al.
        The use of ketamine for acute treatment of pain: a randomized, double-blind, placebo-controlled trial.
        J Emerg Med. 2017; 52: 601-608
        • Soleimanpour H.
        • Hassanzadeh K.
        • Vaezi H.
        • Golzari S.E.
        • Esfanjani R.M.
        • Soleimanpour M.
        Effectiveness of intravenous lidocaine versus intravenous morphine for patients with renal colic in the emergency department.
        BMC Urol. 2012; 12: 13
        • Baranowski A.P.
        • De Courcey J.
        • Bonello E.
        A trial of intravenous lidocaine on the pain and allodynia of postherpetic neuralgia.
        J Pain Symptom Manage. 1999; 17: 429-433
        • Wong C.S.
        • Wong S.H.
        A new look at trigger point injections.
        Anesthesiol Res Pract. 2012; 2012 ([Epub 2011 Sep 29])https://doi.org/10.1155/2012/492452
        • Gamis A.S.
        • Knapp J.F.
        • Glenski J.A.
        Nitrous oxide analgesia in a pediatric emergency department.
        Ann Emerg Med. 1989; 18: 177-181
        • Luhmann J.D.
        • Schootman M.
        • Luhmann S.J.
        • et al.
        A randomized comparison of nitrous oxide plus hematoma block versus ketamine plus midazolam for emergency department forearm fracture reduction in children.
        Pediatrics. 2006; 118: e1078-e1086
        • O'Sullivan Í.
        • Benger J.
        Nitrous oxide in emergency medicine.
        Emerg Med J. 2003; 20: 214-217
        • Strayer R.J.
        • Motov S.M.
        • Nelson L.S.
        Something for pain: responsible opioid use in emergency medicine.
        Am J Emerg Med. 2017; 35: 337-341
        • Patanwala A.E.
        • Keim S.M.
        • Erstad B.L.
        Intravenous opioids for severe acute pain in the emergency department.
        Ann Pharmacother. 2010; 44: 1800-1809
        • Bijur P.E.
        • Kenny M.K.
        • Gallagher E.J.
        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: 362-367
        • Birnbaum A.
        • Esses D.
        • Bijur P.E.
        • et al.
        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: 445-453
        • Patanwala A.E.
        • Edwards C.J.
        • Stolz L.
        • et al.
        Should morphine dosing be weight based for analgesia in the emergency department?.
        J Opioid Manag. 2012; 8: 51-55
        • Lvovschi V.
        • Auburn F.
        • Bonnet P.
        • et al.
        Intravenous morphine titration to treat severe pain in the ED.
        Am J Emerg Med. 2008; 26: 676-682
        • Inturrisi C.E.
        Clinical pharmacology of opioids for pain.
        Clin J Pain. 2012; 18: S3-13
        • Chang A.K.
        • Bijur P.E.
        • Napolitano A.
        • Lupow J.
        • et al.
        Two milligrams i.v. hydromorphone is efficacious for treating pain but is associated with oxygen desaturation.
        J Opioid Manag. 2009; 5: 75-80
        • Sutter M.E.
        • Wintemute G.J.
        • Clarke S.O.
        • et al.
        The changing use of intravenous opioids in an emergency department.
        West J Emerg Med. 2015; 16: 1079-1083
        • Miner J.R.
        • Kletti C.
        • Herold M.
        • et al.
        Randomized clinical trial of nebulized fentanyl citrate versus i.v. fentanyl citrate in children presenting to the emergency department with acute pain.
        Acad Emerg Med. 2007; 14: 895-898
        • Furyk J.S.
        • Grabowski W.J.
        • Black L.H.
        Nebulized fentanyl versus intravenous morphine in children with suspected limb fractures in the emergency department: a randomized controlled trial.
        Emerg Med Australas. 2009; 21: 203-209
        • Borland M.
        • Jacobs I.
        • King B.
        • et al.
        A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the emergency department.
        Ann Emerg Med. 2007; 49: 335-340
        • Wightman R.
        • Perrone J.
        • Portelli I.
        • Nelson L.
        Likeability and abuse liability of commonly prescribed opioids.
        J Med Toxicol. 2012; 8: 335-340
        • Zacny J.P.
        • Lichtor S.A.
        Within-subject comparison of the psychopharmacological profiles of oral oxycodone and oral morphine in non-drug-abusing volunteers.
        Psychopharmacology (Berl). 2008; 196: 105-116
        • Hoppe J.A.
        • Nelson L.S.
        • Perrone J.
        • Weiner S.G.
        Prescribing Opioids Safely in the Emergency Department (POSED) Study Investigators. Opioid prescribing in a cross section of US emergency departments.
        Ann Emerg Med. 2015; 66: 253-259
        • Baehren D.F.
        • Marco C.A.
        • Droz D.E.
        • et al.
        A statewide prescription monitoring program affects emergency department prescribing behaviors.
        Ann Emerg Med. 2010; 56: 19-23
        • Weiner S.G.
        • Griggs C.A.
        • Mitchell P.M.
        • et al.
        Clinician impression versus prescription drug monitoring program criteria in the assessment of drug-seeking behavior in the emergency department.
        Ann Emerg Med. 2013; 62: 281-289
        • Greenwood-Ericksen M.B.
        • Poon S.J.
        • Nelson L.S.
        • Weiner S.G.
        • Schuur J.D.
        Best practices for prescription drug monitoring programs in the emergency department setting: results of an expert panel.
        Ann Emerg Med. 2016; 67: 755-764
        • Smith R.J.
        • Rhodes K.
        • Paciotti B.
        • Kelly S.
        • Perrone J.
        • Meisel Z.F.
        Patient perspectives of acute pain management in the era of the opioid epidemic.
        Ann Emerg Med. 2015; 66: 246-252.e1
        • U.S. Food and Drug Administration (FDA)
        FDA drug safety communication: prescription acetaminophen products to be limited to 325 mg per dosage unit; boxed warning will highlight potential for severe liver failure.
        (Available at:)
        • Centers for Disease Control and Prevention (CDC)
        CDC guideline for prescribing opioids for chronic pain.
        (Available at:)
        • Dillard J.N.
        • Knapp S.
        Complementary and alternative pain therapy in the emergency department.
        Emerg Med Clin North Am. 2005; 23: 529-549
        • Hoffman B.M.
        • Papas R.K.
        • Chatkoff D.K.
        • Kerns R.D.
        Meta-analysis of psychological interventions for chronic low back pain.
        Health Psychol. 2007; 26: 1-9
        • Eisenhart A.W.
        • Gaeta T.J.
        • Yens D.P.
        Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries.
        J Am Osteopath Assoc. 2003; 103: 417-421
        • McReynolds T.M.
        • Sheridan B.J.
        Intramuscular ketorolac versus osteopathic manipulative treatment in the management of acute neck pain in the emergency department: a randomized clinical trial.
        J Am Osteopath Assoc. 2005; 105: 57-68
        • Ault B.
        • Levy D.
        Osteopathic manipulative treatment use in the emergency department: a retrospective medical record review.
        J Am Osteopath Assoc. 2015; 115: 132-137