Non-Opioid Therapies for Pain Management in the ED

Each year in the United States, there are an estimated 141.4 million visits to the emergency department (ED), according to the Centers for Disease Control and Prevention.¹ Pain is the top reason for these encounters, with one study showing pain as a chief complaint in 52.2% of ED cases during a 7-day period.²

“Pain is — and will remain — the most common reason for ED visits,” said Knox H Todd, MD, MPH, FACEP, director of EMLine, an emergency medicine education and practice improvement company, and founding chair of the department of emergency medicine at the University of Texas MD Anderson Cancer Center.

He told Clinical Pain Advisor that while pain management in the ED currently relies heavily on opioids, emergency physicians have begun to expand their range of approaches as part of efforts to reduce opioid-related adverse outcomes. EDs are increasingly using non-opioid analgesic modalities, and “[although] some of these treatments are supported by a robust evidence base, many are not,” noted Dr Todd.

In a paper published in Pain and Therapy in December 2017, Dr Todd reviewed the evidence supporting emerging approaches to pain management in the ED currently used in the United States and Canada, as summarized below.³

• Headache therapies. Opioids remain the first-line therapy for many patients presenting to the ED with benign headache, although substantial data support the use of other treatment modalities.⁴ “Despite well-accepted evidence, progress toward standardizing US and Canadian ED headache treatment and giving primacy to non-opioid interventions of known efficacy (ie, dopamine agonists, serotonin agonists) has been remarkably slow,” he wrote.
• Regional anesthesia. The use of nerve blockade is increasing among ED physicians for pain management in various conditions. In a multicenter randomized trial published in 2016, 161 patients presenting to the ED with acute hip fractures were assigned to 1 of 2 treatments: opioid analgesics alone, or ultrasound-guided, single-injection femoral nerve block delivered by an ED physician, with a subsequent fascia iliaca block inserted within 24 hours by an anesthesiologist.⁵ Opioids were permitted as needed for patients in both groups. The results revealed improved outcomes in the intervention group vs the control group for scores on postoperative day 3 for pain at rest (2.9 vs 3.8; P =.005), locomotion scores on the Functional Independence Measure 6 weeks postinjury (10.3 [vs 9.1; P =.04), and reports of opioid side effects (3% vs 12.4%; P =.03). In addition, the intervention group required 33% to 40% fewer morphine milligram equivalents.
• Ketamine.In the past decade, multiple studies have indicated the effectiveness of subdissociative-dose ketamine in the ED, and the American Academy of Emergency Medicine recently deemed its use — either as monotherapy or in combination with opioids — as safe and effective for acute pain treatment.⁶  A 2017 study indicated that a short infusion of ketamine over a 15-minute period was associated with fewer adverse effects compared with a single intravenous push, with comparable efficacy.⁷ “[ED physicians] should inform patients about potential side effects and avoid ketamine for patients with underlying psychiatric disorders or substance abuse-induced transient psychosis,” noted Dr Todd in his review.³
• Nitrous oxide. Nitrous oxide is commonly used as an analgesic for pediatric patients in the ED, and Dr Todd anticipates that its use will increase among adult patients because of the current focus on reducing opioid use. A 2016 pilot study found self-administered nitrous oxide to be effective and well tolerated by 85 patients in the ED who had moderate to severe pain.⁸

Although several other modalities have shown promise for ED use, including intravenous lidocaine, gabapentinoids, trigger point injections, acupuncture, mind-body techniques, and music therapy, these approaches require further investigation. A program called Alternatives to Opiates Program (ALTO) was launched in 2016 by St. Joseph’s Regional Medical Center in Patterson, New Jersey.⁹ ALTO offers multimodal pain management for 5 conditions, including low back pain and migraine. Treatment includes “non-opioid analgesics, specifically nonsteroidal anti-inflammatory agents, ketamine, lidocaine/ropivacaine, benzodiazepines, corticosteroids, gabapentinoids, and nitrous oxide,”³ and opioids are allowed as rescue therapy. The program also includes patient education, medically assisted opioid addiction treatment, acupuncture, and mind-body approaches. To date, ALTO has reduced opioid use by nearly 50% for certain conditions, according to program administrators.

In addition to specific analgesic therapies, Dr Todd emphasizes the importance of empathy and patient-centered communication, particularly when treating patients with painful conditions. The application of these core physician competencies will likely lead to improved patient satisfaction, treatment compliance, and clinical outcomes, and may also enhance physician well-being while reducing career burnout and medicolegal risk.

Overall, there appears to be a shift underway in emergency pain medicine, as indicated by the increasing numbers of physicians seeking dual certification in emergency medicine and pain management, the new pain management section developed by the American College of Emergency Physicians, and calls for a pain management curriculum for emergency medicine residents.¹⁰ “It is encouraging that a subdiscipline of emergency pain medicine appears to be evolving in the United States, and that increasing numbers of emergency medicine investigators are pursuing pain research and practice,” said Dr Todd.

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References

1. Centers for Disease Control and Prevention. Emergency Department Visits. https://www.cdc.gov/nchs/fastats/emergency-department.htm. Updated May 3, 2017. Accessed March 5, 2018.
2. Cordell WH, Keene KK, Giles BK, Jones JB, Jones JH, Brizendine EJ. The high prevalence of pain in emergency medical care. Am J Emerg Med. 2002;20(3):165-169.
3. Todd KH. A review of current and emerging approaches to pain management in the emergency department. Pain Ther. 2017;6(2):193-202.
4. Gelfand AA, Goadsby PJ. A neurologist’s guide to acute migraine therapy in the emergency room. Neurohospitalist. 2012;2(2):51-59.
5. Morrison RS, Dickman E, Hwang U, et al. Regional nerve blocks improve pain and functional outcomes in hip fracture: a randomized controlled trial. J Am Geriatr Soc. 2016;64(12):2433-2439.
6. Motov S, Rosenbaum S, Vilke GM, Nakajima Y. Is there a role for intravenous subdissociative-dose ketamine administered as an adjunct to opioids or as a single agent for acute pain management in the emergency department? J Emerg Med. 2016;51(6):752-757.
7. 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 of pain in the ED. Am J Emerg Med. 2017;35(8):1095-1100.
8. Herres J, Chudnofsky CR, Manur R, Damiron K, Deitch K. The use of inhaled nitrous oxide for analgesia in adult ED patients: a pilot study. Am J Emerg Med. 2016;34(2):269-273.
9. No authors listed. Innovative program targets five common pain syndromes with non-opioid alternatives. ED Manag. 2016;28(6):61-66.
10. Poon SJ, Nelson LS, Hoppe JA, et al. Consensus-based recommendations for an emergency medicine pain management curriculum. J Emerg Med. 2016;51(2):147-154.