Should analgesia be withheld in patients with acute abdominal pain?

From the Guidelines

No, analgesia should not be withheld in patients with acute abdominal pain. According to the most recent and highest quality study, patients with acute abdominal pain should receive appropriate pain management while diagnostic evaluation proceeds 1. Options include non-opioid analgesic therapies, such as intravenous acetaminophen or ketorolac, rather than opioids as the initial treatment of acute pain.

• Preferentially prescribe nonopioid analgesic therapies (nonpharmacologic and pharmacologic) rather than opioids as the initial treatment of acute pain in patients discharged from the ED, as recommended by the Annals of emergency medicine in 2020 1.
• For cases in which opioid medications are deemed necessary, prescribe the lowest effective dose of a short-acting opioid for the shortest time indicated, as suggested by the same study 1. The outdated concern that pain medication might mask physical exam findings and delay diagnosis has been disproven by multiple studies. In fact, adequate pain control often improves diagnostic accuracy by allowing for a more thorough physical examination as patients can better cooperate and localize their pain.
• Pain itself can cause physiological stress responses that may complicate the clinical picture, highlighting the importance of adequate pain management. When administering analgesia, monitor vital signs, reassess pain levels regularly, and document response to treatment.
• Pain management should be integrated with ongoing diagnostic workup rather than delayed until a definitive diagnosis is reached, ensuring that patients receive timely and effective care.

From the FDA Drug Label

The administration of morphine sulfate injection may obscure the diagnosis or clinical course in patients with acute abdominal condition.

The FDA recommends caution when administering morphine to patients with acute abdominal conditions, as it may obscure the diagnosis or clinical course. Therefore, analgesia should not be withheld solely based on the presence of acute abdominal pain, but rather, it should be administered with caution and careful consideration of the potential risks and benefits. The decision to administer analgesia in patients with acute abdominal pain should be made on a case-by-case basis, taking into account the individual patient's condition and medical history 2. Key considerations include:

• The potential for morphine to obscure the diagnosis or clinical course
• The need for careful monitoring of the patient's condition
• The importance of individualizing treatment and adjusting the dose accordingly
• The risk of adverse reactions, such as respiratory depression and constipation.

From the Research

Analgesia in Patients with Acute Abdominal Pain

• The use of analgesia in patients with acute abdominal pain has been a topic of debate, with some arguing that it may mask symptoms or delay diagnosis 3, 4, 5.
• However, recent studies have shown that the use of opioid analgesia in patients with acute abdominal pain can lead to significant pain reduction without affecting diagnostic accuracy 3, 5, 6.
• A systematic review and network meta-analysis found that there was no significant difference in the intensity of pain between patients who received opioid analgesia and those who received a placebo, and no significant difference in the rate of incorrect diagnoses 6.
• Another study found that the administration of intravenous morphine to patients with acute abdominal pain could lead to a reduction in pain without impairing clinically important diagnostic accuracy 5.

Benefits of Analgesia

• The use of analgesia in patients with acute abdominal pain can improve patient comfort and reduce pain 3, 5, 7.
• A review of the literature found that intravenous administration of paracetamol, dipyrone, or piritramide are currently the analgesics of choice in this clinical setting, and that combinations of non-opioids and opioids should be administered in patients with moderate, severe, or extreme pain 7.
• The use of analgesia can also facilitate diagnosis by reducing the severity of physical symptoms, making it easier for healthcare providers to assess the patient's condition 3.

Safety of Analgesia

• The use of opioid analgesia in patients with acute abdominal pain has been shown to be safe, with no significant increase in adverse events or delays in diagnosis 4, 5, 6.
• A study found that no patients required naloxone after receiving intravenous morphine for acute abdominal pain, and that there were no significant differences in clinically important diagnostic accuracy between patients who received morphine and those who received a placebo 5.
• Another study found that any type of opioid analgesic can be used safely for acute abdominal pain without risk of impairment of diagnostic accuracy 6.