AAEM White Paper on Acute Pain Management in the Emergency Department

AAEM White Paper on Acute Pain Management in the Emergency Department

Sergey Motov, MD FAAEM
Reuben Strayer, MD FRCP FAAEM
Bryan Hayes, PharmD
Mark Reiter, MD MBA FAAEM
Steven Rosenbaum, MD FAAEM
Melanie Richman, MD FAAEM
Zachary Repanshek, MD FAAEM
Scott Taylor, MBBS Benjamin Friedman, MD FAAEM

 

Effective, efficient, and safe pain management is a cornerstone of state-of-the-art patient care in the Emergency Department and is a specialty-defining skill.

The AAEM endorses this document with the hope that all ED patients experiencing acute pain have the option to receive appropriate expeditious, effective, and safe analgesia. The Academy emphasizes that acute pain management in the ED should be patient-specific, pain syndrome-targeted, and based on appropriate non-pharmacological and pharmacological approaches.

 

Acute Pain Management in the ED

EM clinicians and associates who work in an ED should acknowledge and assess a patient’s pain in an empathetic manner by expressing an understanding of the patient’s suffering and a willingness to alleviate pain using a multimodal analgesic approach. EM clinicians should communicate to patients that the goal of ED pain management, particularly in patients who are being discharged, includes restoration of functional ability and is not simply reducing pain; specifically, both emergency physicians and patients must recognize that clinicians are charged with managing pain while managing the potential for some pain medications to cause harm.1-3

Management of acute pain in the ED should be patient-centered, meaning that emergency medicine clinicians should engage patients in shared decision-making by providing patients with details about overall treatment goals and expectations, the natural trajectory of the specific painful condition, and analgesic options including short-term and long-term benefits and risks of adverse effects.4-5

 

Pharmacological Management

 

Non-Opioid Analgesics6

  • Non-steroidal anti-inflammatory drugs (NSAIDs) should be administered at their lowest effective analgesic dose both in the ED and upon discharge. They should be given for the shortest appropriate treatment course. Caution must be exercised when these analgesics are used in patients at risks for renal insufficiency, heart failure, gastrointestina.
  • When a patient’s acute painful condition (e.g., sprains, strains, bruises) warrant an NSAID but there are contraindications to their systemic use, strong consideration should be given to topical preparations (e.g., diclofenac gel) or other topical analgesics such as lidocaine patches.10-12
  • Oral and rectal forms of acetaminophen either alone or in combination with other analgesics provide similar analgesia to intravenous acetaminophen but with slower onset of action. For patients who have contraindications to oral and rectal routes, the intravenous route is preferred.13
  • Emergency clinicians should consider regional and local nerve blocks for traumatic and nontraumatic painful conditions, alone or in combination with pharmacological and nonpharmacological treatment modalities.14
  • Sub-dissociative dose ketamine (SDK), administered alone or as part of a multimodal analgesic approach may be considered in the ED. Emergency clinicians should counsel patients that there is a high likelihood of minor but at times bothersome psychoperceptual side effects. Sub-dissociative ketamine should be administered under the same policies as other analgesics.15-19
  • Limited data suggest that administration of intravenous lidocaine may alleviate specific painful conditions (renal colic, herpetic/post-herpetic neuralgia) and should be considered for patients without pre-existing structural heart disease and rhythm disturbances.20,21
  • EM clinicians should consider using trigger point injections with local anesthetics (Lidocaine, Bupivacaine) for patients with acute myofascial painful conditions such as back pain.22
  • EM clinicians should consider utilization of nitrous oxide for the treatment of acute painful conditions in the ED either alone or as an adjunct to other analgesics.23

 

Opioid Analgesics

Emergency Medicine clinicians are uniquely positioned to combat the opioid epidemic by thoughtful prescribing of parenteral and oral opioids in the ED and upon discharge, and through their engagement with opioid addicted patients in the ED. Given the known harms of opioid analgesics, EM clinicians should make every effort to utilize non-pharmacological modalities and non-opioid analgesics to alleviate pain in the ED and especially on discharge, and to use opioid analgesics only when the benefits of opioids are felt to outweigh the harms.3

 

In the ED:

  • Parenteral opioids when used in titratable fashion are effective, safe, and easily reversible analgesics that quickly relieve pain.24-28
  • Emergency clinicians should consider administering these analgesics for patients in acute pain where the likelihood of analgesic benefit is judged to exceed the likelihood of harm.
  • Parenteral opioids should be titrated regardless of the initial dosing regimen (i.e., weight-based, fixed, or nurse-initiated) at 20-30 min intervals until pain is relieved to acceptable levels with frequent re-assessment and evaluation for development of opioid-related adverse effects.24-28
  • A reasonable approach to parenteral opioid management involves using lower doses initially and titrating to higher doses as needed.27,28
  • At higher doses, however, opioids cause respiratory depression. Therefore, patients in acute pain who are not accustomed to opioids and who are administered higher doses of opioids should have their respiratory status monitored.26
  • Hydromorphone use in the ED should be utilized with caution due to potential for dosing errors leading to dangerous respiratory and central nervous system depression. Should hydromorphone be administered in higher than equianalgesic morphine milligram equivalents, close cardiopulmonary monitoring is strongly recommended.29,30
  • When parenteral opioids are used, patients should be engaged in shared-decision making regarding the route of administration, as repetitive attempts of IV cannulation and intramuscular injections are associated with pain. In addition, intramuscular injections are associated with unpredictable absorption rates, and complications such as muscle necrosis, soft tissue infection and the need for dose escalation.
  • When intravascular access is unobtainable, EM clinicians should consider utilization of intranasal (fentanyl), nebulized (fentanyl and morphine), or transmucosal (rapidly dissolvable fentanyl tablets) routes of analgesic administration for patients with acute painful conditions.31-33
  • Oral opioid administration is effective for most patients in the ED, however, while there is no appreciable analgesic difference between commonly used opioids (oxycodone, hydrocodone and morphine), immediate release morphine sulfate administration is associated with lesser degree of euphoria and consequently, less abuse potential.34,35
  • EM clinicians and other acute care providers without clinic-based practices and specialized expertise in pain management should not administer or prescribe long-acting, extended-release, or sustained-release opioid formulations, which include both oral and transdermal (fentanyl) medications in the ED. These formulations (long-acting, extended- or sustained-release opioids) are not indicated for acute pain and carry a high risk of overdose, particularly in opioid-naïve patients.36
  • EM clinicians should follow their state’s specific regulatory requirements for accessing a prescription drug monitoring program when prescribing opioids for acute pain in the ED. If voluntary, emergency medicine clinicians should strongly consider routinely accessing this database. The information obtained should be used to inform prescribing, to identify and counsel patients with aberrant-drug related behaviors, and to offer referral for addiction treatment.37-39

 

Upon discharge from the ED,

  • EM clinicians should involve patients in shared decision-making by discussing the benefits and harms (short-term and long-term) and alternative analgesic modalities.3,4
  • If a patient’s acute painful condition warrants opioid analgesics, EM clinicians should prescribe only immediate-release formulations at the lowest effective dose and for the shortest course (generally 2-3 days’ supply).3
  • EM clinicians should consider co-prescribing opioid and non-opioid analgesics at discharge whenever possible.
  • Special caution should be taken when prescribing combinations of acetaminophen-oxycodone and acetaminophen-hydrocodone as to not exceed the maximum daily dose of acetaminophen as to decrease potential of liver injury. (https://www.fda.gov/Drugs/DrugSafety/ucm239821.htm)
  • EM clinicians should evaluate the patient’s medical history when opioids are considered as a discharge prescription. Patients with or at risk for obstructive sleep apnea or with pulmonary disease are at increased risk for respiratory depression. Patients with a history of substance abuse and family history of addiction are at an increased risk for relapse of their use disorder.3
  • Patients discharged with an opioid prescription should be counseled regarding common adverse effects related to opioid use such as pruritus and constipation as well as more serious adverse effects as sedation, respiratory depression, the development of tolerance and dependence (which can occur within days), and the risk of developing opioid use disorder.3
  • Patients discharged with an opioid prescription should be counseled about safe opioid storage and disposal, as well the consequences of failure to do this.3
  • Emergency clinicians should consider non-pharmacological and non-opioid analgesics modalities for patients presenting to the ED with exacerbations of chronic pain, as opioid analgesics are more likely to cause harm than benefit in these cases. Opioids should be prescribed for chronic pain a physician who will provide ongoing care and can use opioids as part of an analgesic care plan that includes specific analgesic and functional goals as well as opioid contract. Emergency clinicians should attempt to contact patient’s principle opioid prescriber prior to prescribing an opioid analgesic for exacerbation of chronic pain, however, should patient require an opioid analgesic, a short course (up to 3 days) of immediate release opioids might be prescribed at discharge from the ED. (https://www.cdc.gov/drugoverdose/prescribing/guideline.html)

 

Non-Pharmacological Management40,41

  • ED clinicians should consider applications of heat or cold and specific recommendations for activity and exercise, and/or early referral to physical therapy.
  • The use of alternative and complementary therapies, such as acupuncture, guided imagery, cognitive-behavioral therapy, and hypnosis, have not been systematically evaluated for use in the ED. In general, their application may be limited in the context of an ED, although continued investigation into their safety and efficacy is strongly encouraged.40
  • ED clinicians might consider utilization of osteopathic manipulation techniques (high-velocity-lowamplitude techniques, muscle energy techniques, and soft tissue techniques) for patients presenting to the ED with pain syndromes of skeletal, arthrodial, and myofascial origins.42-44

 

References:

1. Chang HY, Daubresse M, Kruszewski SP, et al. Prevalence and treatment of pain in EDs in the United States, 2000 to 2010. Am J Emerg Med 2014;32(5):421–31.

2. Green SM. There is oligo-evidence for oligoanalgesia. Ann Emerg Med 2012;60: 212–4.

3. Strayer RJ, Motov SM, Nelson LS. Something for pain: Responsible opioid use in emergency medicine. Am J Emerg Med. 2017 Feb;35(2):337-341.

4. Smith RJ, Rhodes K, Paciotti B, Kelly S,et al. Patient Perspectives of Acute Pain Management in the Era of the Opioid Epidemic. Ann Emerg Med. 2015 Sep;66(3):246-252

5. Meisel ZF, Smith RJ. Engaging patients around the risks of opioid misuse in the emergency department. Pain Manag. 2015 Sep;5(5):323-6.

6. Ducharme J. Non-opioid pain medications to consider for emergency department patients. Available at: http://www.acepnow.com/article/non-opioid-painmedications-consider-emergencydepartment-patients/. Accessed February 11, 2015.

7. 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;35:1127–46.

8. Wright JM, Price SD, Watson WA. NSAID use and efficacy in the emergency department: single doses of oral ibuprofen versus intramuscular ketorolac. Ann Pharmacother 1994;28(3):309–12.

9. Catapano MS. The analgesic efficacy of ketorolac for acute pain [review]. J Emerg Med 1996;14(1):67–75.

10. McCarberg B, D'Arcy Y. Options in topical therapies in the management of patients with acute pain. Postgrad Med. 2013 Jul;125(4 Suppl 1):19-24.

11. Derry S, Moore RA, Gaskell H, McIntyre M, Wiffen PJ. Topical NSAIDs for acute musculoskeletal pain in adults. Cochrane Database Syst Rev. 2015 Jun 11;(6):CD007402

12. Derry S, Conaghan P, Da Silva JA, Wiffen PJ, Moore RA. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2016 Apr 22;4:CD007400.

13. Yeh YC, Reddy P. Clinical and economic evidence for intravenous acetaminophen. Pharmacotherapy 2012;32(6):559–79.

14. Ritcey B, Pageau P, Woo MY, Perry JJ. Regional Nerve Blocks For Hip and Femoral Neck Fractures in the Emergency Department: A Systematic Review. CJEM. 2016 Jan;18(1):37-47. doi: 10.1017/cem.2015.75. Epub 2015 Sep 2.

15. Beaudoin FL, 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, doubleblind, clinical trial. Acad Emerg Med 2014;21(11):1193–202.

16. 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(3):222–9.

17. Goltser A, Soleyman-Zomalan E, Kresch F, et al. Short (low-dose) ketamine infusion for managing acute pain in the ED: case-report series. Am J Emerg Med 2015;33(4):601.

18. Motov S, Mai M, Pushkar I, Likourezos A ,et al. A prospective randomized, double-dummy trial comparing intravenous push dose of low dose ketamine to short infusion of low dose ketamine for treatment of moderate to severe pain in the emergency department. Am J Emerg Med. 2017 Mar 3. pii: S0735-6757(17) 30171-7

19. 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 May;52(5):601-608

20. Soleimanpour H, Hassanzadeh K, Vaezi H, et al. Effectiveness of intravenous lidocaine versus intravenous morphine for patients with renal colic in the emergency department. BMC Urol 2012;12-17.

21. Baranowski AP, De Courcey J, Bonello E. A trial of intravenous lidocaine on the pain and allodynia of postherpetic neuralgia. J Pain Symptom Manage. 1999 Jun;17(6):429-33

22. Wong CS, Wong SH. A new look at trigger point injections. Anesthesiol Res Pract. 2012;2012:492452. doi: 10.1155/2012/492452. Epub 2011 Sep 29.

23. Luhmann JD, Schootman M, Luhmann SJ, 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(4):e1078–86.

24. Patanwala AE, Keim SM, Erstad BL. Intravenous opioids for severe acute pain in the emergency department. Ann Pharmacother 2010;44(11):1800–9.

25. Bijur PE, Kenny MK, Gallagher EJ. Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients. Ann Emerg Med 2005; 46:362–7.

26. Birnbaum A, Esses D, Bijur PE, 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(4):445–53.

27. Patanwala AE, Edwards CJ, Stolz L, et al. Should morphine dosing be weight based for analgesia in the emergency department? J Opioid Manag 2012; 8(1):51–5.

28. Lvovschi V, Auburn F, Bonnet P, et al. Intravenous morphine titration to treat severe pain in the ED. Am J Emerg Med 2008;26:676–82.

29. Chang AK, Bijur PE, 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 MarApr;5(2):75-80.

30. Sutter ME, Wintemute GJ, Clarke SO, et al. The changing use of intravenous opioids in an emergency department. West J Emerg Med 2015;16:1079-83.

31. Miner JR, 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;14:895–8.

32. Furyk JS, Grabowski WJ, Black LH. Nebulized fentanyl versus intravenous morphine in children with suspected limb fractures in the emergency department: a randomized controlled trial. Emerg Med Australas 2009;21:203–9.

33. 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;49:335–40

34. Wightman R, Perrone J, Portelli I, et al. Likeability and Abuse Liability of Commonly Prescribed Opioids. J Med Toxicol. September 2012. doi: 10.1007/s12181-012-0263-x

35. Zacny JP, Lichtor SA. Within-subject comparison of the psychopharmacological profiles of oral oxycodone and oral morphine in non-drug-abusing volunteers. Psychopharmacology (Berl) 2008 Jan;196(1):105–16. 36. Hoppe JA, Nelson LS, Perrone J, Weiner SG, 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(3):253–259.

37. Baehren DF, Marco CA, Droz DE, et al. A statewide prescription monitoring program affects emergency department prescribing behaviors. Ann Emerg Med. 2010; 56(1):19–23

38. Weiner SG, Griggs CA, Mitchell PM, 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(4):281–9.

39. Greenwood-Ericksen MB, Poon SJ, Nelson LS, Weiner SG, et al. Best Practices for Prescription Drug Monitoring Programs in the Emergency Department Setting: Results of an Expert Panel. Ann Emerg Med. 2016 Jun;67(6):755-764

40. Dillard JN, Knapp S. Complementary and alternative pain therapy in the emergency department. Emer Med Clin No Amer. 2005;23:529–549

41. Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of psychological interventions for chronic low back pain. Health psychology:official journal of the Division of Health Psychology, American Psychological Association. 2007;26(1):1-9

42. Eisenhart AW, Gaeta TJ, Yens DP. Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries. J Am Osteopath Assoc. 2003;103:417–421

43. McReynolds TM, Sheridan BJ. 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

44. Ault B, Levy D. Osteopathic manipulative treatment use in the emergency department: a retrospective medical record review. J Am Osteopath Assoc. 2015 Mar;115(3):132-7

 

Approved: 10/24/17