Acute Pain Management

Aka: Acute Pain Management, Emergency Department Pain Management, Acute Pain Control in the Emergency Department, Acute Pain Control, Opioid Use in the Emergency Department, Acute Severe Pain, Acute Pain Stepped Oral Analgesics, Oral Analgesic, Acute Severe Pain Out of Proportion

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II. Causes: Acute Severe Pain Out of Proportion to Clinical Findings

  1. Gastrointestinal or Genitourinary
    1. Renal Colic
    2. Splenic Infarct
    3. Diaphragmatic Hernia
    4. Intussusception
    5. Acute Pancreatitis
    6. Superior Mesenteric Artery Occlusion
    7. Testicular Torsion
  2. Acute Painful Syncope
    1. Abdominal Aortic Aneurysm rupture
    2. Aortic Dissection
    3. Ectopic Pregnancy with rupture
    4. Subarachnoid Hemorrhage
    5. Acute Coronary Syndrome
    6. Pulmonary Embolism
  3. Musculoskeletal
    1. Compartment Syndrome
    2. Necrotizing Fasciitis
    3. Occult Fracture
      1. Pelvic Fracture
      2. Femur Fracture
      3. Tibial Plateau Fracture
  4. Miscellaneous Disorders
    1. Acute Angle-Closure Glaucoma
    2. Sickle Cell Crisis
    3. Early Shingles (first 72 hours before rash development)

III. Management: Acute Pain

  1. Treat new acute, painful conditions regardless of Opiate history while patient is in the emergency department
    1. Examples: Long bone Fractures, Appendicitis, Renal Colic, Acute Cholecystitis
    2. Rapid control of acute symptoms in the emergency department
    3. Pain is considered an emergency condition by EMTALA
    4. Set reasonable expectations for Acute Pain Management (improved but not 100% resolved)
  2. Paranteral Opioid approach (if indicated)
    1. Control pain early with serial doses of Opioids and frequent reassessment
    2. Early definitive control of pain breaks the pain cycle
    3. Avoid under-treating with small, ineffective doses
  3. Consider Non-Opioid Analgesics and other measures
    1. See Below
  4. Use stepped approach to home Acute Pain Management
    1. See Acute Pain Stepped Oral Analgesics as below
    2. Gear Oral Analgesic starting point based on response to acute Pain Medications in ED
    3. Use Acetaminophen and NSAIDs in combination (if not contraindicated)
      1. Common approach
        1. Acetaminophen 1000 mg orally every 6 hours AND
        2. Ibuprofen 400 to 600 mg orally every 6 to 8 hours
      2. Study used Ibuprofen 200 mg with Acetaminophen 500 mg
        1. Very effective for post-operative pain without the risks of Opioids
        2. Derry (2013) Cochrane Database Syst Rev (6):CD010210 +PMID:23794268 [PubMed]
    4. Consider adjunctive topical agents
      1. Diclofenac Gel
      2. Lidocaine Patch (4% patch is OTC and typically <$10 for 5 patches as of 2018)
      3. TENS unit
    5. Avoid Tramadol
      1. Equivalent to Non-Opioid Analgesics (but with increased Drug Interactions)
    6. Opioid management
      1. The best prevention of Opioid Abuse is in keeping Opioid naive patients, Opioid naive
        1. Long term Opioid use occurs in 1 in 50 Opioid-naive patients with Opioid prescription
        2. Weigh the benefit (over non-Opioids, which may be marginal) versus the risk of addiction
          1. Imagine a bottle of 50 Opioid pills (e.g. Oxycodone)
          2. Of these, 49 may help the pain, but 1 will result in longterm use and abuse risk
          3. Would you take these pills?
        3. References
          1. Strayer (2020) EM:Rap 20(6): 2-3
      2. Prescribe a short course for 2-3 days of acute pain to allow for follow-up and re-evaluation (e.g. 8 tablets)
        1. See Opioid Prescribing Quantity
      3. Encourage to use other non-Opioid agents first, and limit Opioids to pain interfering with sleep
      4. Consider Morphine immediate release for adults moderate to severe pain
        1. Morphine IR 15 mg PO is equivalent to 5 mg IV
        2. Start with 7.5 mg orally every 4-6 hours as needed
        3. Morphine is less euphoric than Oxycodone and Hydrocodone
  5. Employ non-pharmacologic measures
    1. See Musculoskeletal Injury Management (e.g. RICE-M, Contrast Baths)
    2. Reduce provocative activities (e.g. crutch walking, work limitations)
    3. Avoid inactivity and maintain range of motion
    4. Consider physical therapy
  6. Short outpatient course of Acute Pain Management
    1. Close follow-up with primary care to reassess pain management
    2. Home Opioids (if indicated) should be limited to 3-7 days
      1. Counsel that prolonged Opioid use is a risk for dependence
  7. References
    1. (2015) Presc Lett 22(4)
    2. Birnbaumer (2013) Analgesia and Procedural Sedation, EM Bootcamp, CEME Lecture

IV. Management: Acute Pain Stepped Oral Analgesics

  1. See Pediatric Analgesics
  2. Step 1: Acetaminophen with or without Ibuprofen
    1. Acetaminophen 1000 mg orally every 6 hours
      1. Considered best first-line Oral Analgesic
      2. Safe and effective for most mild to moderate pain
      3. Does not have antiinflammatory activity
    2. Ibuprofen 400 to 600 mg orally every 6 hours
      1. GI safety similar to Placebo up to 1200 mg/day
      2. More effective in Dental Pain and Dysmenorrhea
      3. Antiinflammatory activity starts at 600 mg doses
  3. Step 2
    1. Advance to higher Ibuprofen 600-800 mg or Naproxen 500 mg dosages or
    2. Switch to another NSAID class (e.g. Sulindac) or COX2 Inhibitor (e.g. Celebrex)
  4. Step 3
    1. Consider adjunctive topical agents (e.g. Diclofenac Gel, Lidoderm patch or TENS unit)
  5. Step 4
    1. Morphine IR 7.5 mg (one half of 15 mg tablet) orally every 4-6 hours
      1. Consider Morphine instead of Oxycodone or Hydrocodone (Morphine is less euphoric)
    2. Oxycodone (Roxicodone) 5 mg every 4-6 hours or
    3. Combination Agents
      1. Non-combination agents (Morphine or Oxycodone) are preferred
        1. Non-combination agents allow for continued scheduled NSAID and Tylenol
        2. Opioid is only taken if there is break through pain (e.g. night pain)
        3. Combination agents risk dosing complexity and Acetaminophen Overdose
      2. Oxycodone with Acetaminophen (Percocet)
      3. Hydrocodone-Acetaminophen (Vicodin) 5/325 to 10/650 every 6 hours prn
  6. Step 5
    1. Convert to SR when daily dose established
    2. Morphine (immediate release) 15-30 mg every 4-6 hours prn or
    3. Dilaudid 2-4 mg orally every 4-6 hours prn
  7. Consider Topical Analgesic (see step 3 above)
    1. Topical NSAID (Diclofenac)
    2. Lidocaine Patch (Lidoderm)
    3. Capsaicin
  8. Consider Systemic adjunctive medications if pain persists
    1. See Chronic Pain Management
    2. Tricyclic Antidepressants (e.g. Amitriptyline)
    3. Anticonvulsants (e.g. Gabapentin)
  9. Avoid Analgesics with poor efficacy and increased adverse effect risks
    1. Codeine (e.g. Tylenol #3)
    2. Propoxyphene (Darvon, Darvocet)
    3. Tramadol (Ultram)

V. Management: Acute pain Non-Opioid ParenteralAnalgesics

  1. Typical ParenteralAnalgesics
    1. Ketorolac (Toradol) 10-15 mg IV
    2. Acetaminophen 1000 mg oral or IV (over 15 min)
  2. Novel Acute Pain Management strategies (use with caution only)
    1. Obtain Informed Consent and review dosing, adverse effects and risks prior to use
    2. Ketamine 0.2 mg/kg IV over 10 min, then 0.15 mg/kg/hour
    3. Lidocaine 2% at 1.5 to 2.5 mg/kg/h IV for 2-4 hours
    4. Clonidine 0.3 to 2 mcg/kg/h IV infusion
    5. Dexemedetomidine 0.2 to 0.3 mcg/kg/h IV infusion
  3. Acute Abdominal Pain
    1. Ketorolac (esp. for suspected Renal Colic)
    2. Ketamine (see above)
  4. Acute Headache
    1. IV crystalloid hydration (NS, LR) AND
    2. Ketorolac AND
    3. Diphenhydramine AND
    4. Prochlorperazine, Metoclopramide or Olanzapine
  5. Non-radicular back pain
    1. Ketorolac
    2. Trigger Point Injection
    3. Ketamine
    4. Lidocaine Patch
  6. Acute neuropathic pain or back pain
    1. Gabapentin (Neurontin) 300 mg orally
    2. Corticosteroid (Prednisone or Methylprednisolone)
    3. Typical and novel approaches as above
  7. Regional pain management
    1. Peripheral Nerve Block
  8. References
    1. Hipskind and Kamboj (2016) Crit Dec Emerg Med 30(10): 15-23

VI. Evaluation: Determine if presenting complaint is an exacerbation of Chronic Pain

  1. Review medical record
    1. Medication refills (especially Opioids)
    2. Clinic and emergency department visits for painful conditions
  2. Review Prescription Drug Monitoring Programs (alliance of states sites)
    1. http://www.pmpalliance.org/content/pmp-access
  3. Determine if patient is in a pain program
    1. Review Controlled Substance Agreement
    2. Communicate with primary pain provider if available
      1. Alternatively, notify them that patient was seen for pain in Emergency Department
  4. Ask about Chemical Dependency and prescribed medication misuse
    1. Drug Diversion
    2. Chemical Dependency
    3. Recreational use of prescription medications
    4. History of prescription drug Overdose
  5. Be respectful
    1. Assess patients appropriately without immediately stereotyping or discounting their presenting symptoms
    2. Articulate to the patient what is doable for pain management (e.g. 30% reduction in pain, such as 6/10 to a 3-4/10)
  6. Discuss follow-up, alternatives and expectations
    1. Direct patients to follow-up within 1 week with primary care or pain management
    2. Patient should consider neuropathic Pain Medications (e.g. Gabapentin, Tricyclic Antidepressants, Duloxetine)
    3. Avoid Opioid doses above 50 mg/day Morphine Equivalents for non-cancer Chronic Pain
    4. Opioid doses >90 mg/day Morphine Equivalents for non-cancer, non-Palliative Care is a red flag
    5. Function that does not improve 30% on Chronic Opioids should be weaned (slowly, 10% every 1-2 weeks)
    6. (2016) Presc Lett 23(5): 25
  7. Informed Consent for Opioid Prescription
    1. See Opioid Prescription in Acute Pain
    2. Review goal of improved function (not complete pain elimination)
    3. Review short-term Opioid course
    4. Review risks of longterm tolerance, dependence and addiction with longer use

VII. Management: Exacerbation of Chronic Pain

  1. Consider establishing an emergency department care plan for Chronic Pain patients
    1. Does not replace an outpatient pain management program or primary care provider management
    2. Creates a consistent plan of pain management across a group of emergency providers
    3. Reviews specific patient resources, contacts, and precautions in treating the patient's pain
  2. Review flare management
    1. See Chronic Pain Flare Management
  3. Patient not in pain program
    1. Discuss the problem with emergency department delivery of Chronic Pain Management
    2. Encourage close follow-up with primary care
    3. Encourage establishing with a pain management program
    4. Review that pain programs exist with better longterm outcomes
      1. Chronic Pain Management
      2. Chronic Narcotic Guideline

VIII. Resources

  1. Opioid Alternatives Chart (CERTA)
    1. https://my.visme.co/projects/mxn9rzqw-certa-2#s1

IX. References

  1. Hipskind and Kamboj (2016) Crit Dec Emerg Med 30(10): 15-23
  2. Jaben in Herbert (2012) EM: Rap 12(9): 8

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