What are the pain management options in the Emergency Department (ED)?

From the Guidelines

Pain management in the emergency department should prioritize nonopioid analgesic therapies, such as acetaminophen and NSAIDs, over opioids as the initial treatment for acute pain, as recommended by the most recent and highest quality study 1.

Key Considerations

• Nonopioid analgesics, including acetaminophen (1000 mg IV/PO every 6 hours) and NSAIDs like ibuprofen (400-600 mg PO every 6 hours) or ketorolac (15-30 mg IV/IM), should be the first-line treatment for acute pain in the emergency department.
• Opioids, such as morphine, hydromorphone, or fentanyl, may be necessary for moderate to severe pain, but should be prescribed at the lowest effective dose for the shortest time indicated, as recommended by 1.
• Regional anesthesia techniques, like nerve blocks, and non-pharmacological approaches, including positioning, ice/heat application, and distraction techniques, can provide targeted relief and complement medication therapy.

Monitoring and Titration

• When administering opioids, monitor for respiratory depression, hypotension, and nausea, and have naloxone readily available.
• Titrate medications based on pain scores (0-10 scale) assessed regularly.

Discharge Instructions

• Provide clear instructions on medication schedules, potential side effects, and follow-up care for patients being discharged from the emergency department.

Rationale

The approach to pain management in the emergency department should prioritize nonopioid analgesics and use opioids judiciously, as supported by the most recent and highest quality study 1, to minimize the risks of opioid-related adverse effects and promote effective pain relief.

From the FDA Drug Label

Morphine sulfate is an opioid agonist indicated for the management of pain not responsive to non-narcotic analgesics. Individualize treatment in every case, using non-opioid analgesics, opioids on an as needed basis and/or combination products, and chronic opioid therapy in a progressive plan of pain management The usual starting dose in adults is 0.1 mg to 0.2 mg per kg every 4 hours as needed to manage pain.

Pain management options in the emergency department include the use of morphine sulfate injection for patients with pain not responsive to non-narcotic analgesics.

• The dose should be individualized for each patient, taking into account their prior analgesic treatment experience, opioid tolerance, and medical status.
• The usual starting dose is 0.1 mg to 0.2 mg per kg every 4 hours as needed to manage pain.
• Administration of morphine sulfate injection should be limited to use by those familiar with the management of respiratory depression 2.

From the Research

Pain Management Options

• Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatment options for most patients with acute mild to moderate pain 3
• Topical NSAIDs are recommended for non-low back, musculoskeletal injuries 3
• Adjunctive medications may be added as appropriate for specific conditions if the recommended dose and schedule of first-line agents are inadequate 3
• For severe or refractory acute pain, treatment can be briefly escalated with the use of medications that work on opioid and monoamine receptors (e.g., tramadol, tapentadol) or with the use of acetaminophen/opioid or NSAID/opioid combinations 3

Non-Opioid Alternatives

• Multiple independent literature searches have identified numerous opioid and nonopioid alternatives available for the treatment of pain 4
• Care should be tailored to the patient based on their specific acute painful condition and underlying risk factors and comorbidities 4
• 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 4

Trauma Patients

• Systematic assessment of pain on admission to the emergency department (ED) is a cornerstone of translating the best treatment strategies for patient care into practice 5
• Pain must be measured with severity scales that are validated in clinical practice, including for specific populations (such as children and older adults) 5
• A multimodal pain approach, which involves the use of two or more drugs with different mechanisms of action, plays an important role in the relief of trauma pain 5
• Inhaled analgesia techniques and ultrasound-guided nerve blocks are also increasingly effective solutions 5

Evidence-Based Approach

• An evidence-based approach to traumatic pain management in the emergency department involves understanding the pathophysiology, historical factors, diagnostic strategies, and demographics that influence the experience of pain 6
• Regional anesthetic techniques and nonpharmacologic means can help minimize the use of systemic agents that may have unwanted side effects 6
• Diagnostic evaluation should not detract from symptomatic treatment 6

Clinical Review

• The ever-growing research on emergency department analgesia has challenged the current practices with respect to the optimal analgesic regimen for acute musculoskeletal pain, safe and judicious opioid prescribing, appropriate utilization of non-opioid therapeutics, and non-pharmacological treatment modalities 7
• This clinical review provides evidence-based answers to these challenging questions 7