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EMERGENCY MEDICINE PRACTICE
A N E V I D E N C E - B A S E D A P P ROAC H T O E M E RG E N C Y M E D I C I N E
Pain Management In The ED:
Prompt, Cost-Effective,
State-Of-The-Art Strategies
“Pain is inevitable; suffering is optional.”
TINGY, miserly, parsimonious, chintzy, meagerly, closefisted, tight,
“Spenurious,
and frugal.” Does this describe some erstwhile Scrooge, or
the modern emergency physician, gingerly dosing pain medication to the
suffering? Perhaps both.
Of all of the symptoms that prompt patients to seek emergency
care, none is as prevalent as acute pain.1 Each year in the United
States, millions of patients present to EDs for the treatment of acutely
painful conditions. Pain costs millions of lost workdays and billions
of dollars annually.
Apart from the issues of compassion and patient satisfaction, there
are positive physiologic benefits to treating acute pain. Conversely, there
are abundant negative physiologic consequences to inadequately treating
pain. In postoperative patients, effective early pain management will
decrease postoperative complications and shorten ICU and hospital
stays.2 Physiologically, unrelieved pain increases the metabolic rate, alters
the immune response, and delays return to normal function. Acute pain
has short-term psychological consequences, while chronic pain can cause
depression and even suicide.
Given the magnitude of painful conditions, and the wide availability
of inexpensive analgesics, aggressive management of pain is humane and
cost-effective. Unfortunately, emergency physicians often neglect to treat
this symptom, needlessly prolonging suffering. This tendency to undertreat pain is called oligoanalgesia.
In a frequently cited ED study, fewer than 50% of patients with
painful conditions received any analgesia. Of those who were treated,
more than half waited over an hour to receive their first dose of medication.3 Numerous studies echo these results. In one, fewer than one-tenth of
patients in pain received analgesics in the ED.4 In another investigation,
only 20% of patients with extremity fractures were given analgesics in the
Editor-in-Chief
Stephen A. Colucciello, MD, FACEP,
Director of Clinical Services,
Department of Emergency
Medicine, Carolinas Medical
Center, Charlotte, NC; Assistant
Clinical Professor, Department of
Emergency Medicine, University of
North Carolina at Chapel Hill, Chapel
Hill, NC.
Editorial Board
Judith C. Brillman, MD, Residency
Director, Associate Professor,
Department of Emergency
Medicine, The University of
New Mexico Health Sciences
Center School of Medicine,
Albuquerque, NM.
W. Richard Bukata, MD, Assistant
Clinical Professor, Emergency
Medicine, Los Angeles County/
USC Medical Center, Los Angeles,
CA; Medical Director, Emergency
Department, San Gabriel
Valley Medical Center, San
Gabriel, CA.
Francis M. Fesmire, MD, FACEP,
Director, Chest Pain—Stroke Center,
Erlanger Medical Center; Assistant
Professor of Medicine, UT College of
Medicine, Chattanooga, TN.
Michael J. Gerardi, MD, FACEP, Clinical
Assistant Professor, Medicine,
University of Medicine and Dentistry
of New Jersey; Director, Pediatric
Emergency Medicine, Children’s
Medical Center, Atlantic Health
System; Chair, Pediatric Emergency
Medicine Committee, ACEP.
Michael A. Gibbs, MD, FACEP,
Clinical Instructor, University of
North Carolina at Chapel Hill;
Medical Director, MedCenter Air,
Department of Emergency
Medicine, Carolinas Medical
Center, Charlotte, NC.
Gregory L. Henry, MD, FACEP, CEO,
Medical Practice Risk Assessment,
Inc., Ann Arbor, MI; Clinical Professor,
Section of Emergency Services,
Department of Surgery, University
of Michigan Medical School, Ann
Arbor, MI; President, American
Physicians Assurance Society, Ltd.,
Bridgetown, Barbados, West Indies;
Past President, ACEP.
Jerome R. Hoffman, MA, MD, FACEP,
Professor of Medicine/Emergency
Medicine, UCLA School of Medicine;
Attending Physician, UCLA
Emergency Medicine Center;
December 1999
Volume 1, Number 7
Author
Michael A. Turturro, MD, FACEP
Vice Chair and Director of Academic Affairs,
Department of Emergency Medicine, The Mercy
Hospital of Pittsburgh; Clinical Associate Professor
of Emergency Medicine, University of Pittsburgh
School of Medicine, Pittsburgh, PA.
Peer Reviewer
James Ducharme, MD, CM, FRCP
Associate Professor, Department of Emergency
Medicine, Dalhousie University, Saint John, New
Brunswick, Canada.
CME Objectives
Upon completing this article, you should be
able to:
1. discuss barriers to effective analgesia in
the ED;
2. list advantages and disadvantages of
opioid and non-narcotic analgesics;
3. discuss appropriate doses and routes of
opioid analgesics; and
4. discuss the use of local anesthetics and
sedative agents for pain control in the ED.
Date of original release: December 1, 1999.
Date of most recent review: November 24, 1999.
See “Physician CME Information” on back page.
Co-Director, The Doctoring Program,
UCLA School of Medicine, Los
Angeles, CA.
Andy Jagoda, MD, FACEP, Associate
Professor of Emergency Medicine,
Mount Sinai School of Medicine,
New York, NY.
John A. Marx, MD, Chair and Chief,
Department of Emergency
Medicine, Carolinas Medical
Center, Charlotte, NC; Clinical
Professor, Department of
Emergency Medicine, University
of North Carolina at Chapel Hill,
Chapel Hill, NC.
Michael S. Radeos, MD, FACEP,
Attending Physician in Emergency
Medicine, Lincoln Hospital, Bronx,
NY; Research Fellow in Emergency
Medicine, Massachusetts General
Hospital, Boston, MA; Research
Fellow in Respiratory Epidemiology,
Channing Lab, Boston, MA.
Steven G. Rothrock, MD, FACEP, FAAP,
Assistant Professor of Emergency
Medicine, University of Florida;
Orlando Regional Medical Center,
Orlando, FL.
Alfred Sacchetti, MD, FACEP,
Research Director, Our Lady of
Lourdes Medical Center, Camden,
NJ; Assistant Clinical Professor
of Emergency Medicine,
Thomas Jefferson University,
Philadelphia, PA.
Mark Smith, MD, Chairman,
Department of Emergency
Medicine, Washington Hospital
Center, Washington, DC.
Thomas E. Terndrup, MD, Professor
and Chair, Department of
Emergency Medicine, University
of Alabama at Birmingham,
Birmingham, AL.
Fear Of Obscuring The Diagnosis
ED; just one-fifth were given a prescription (or even a
recommendation) for an analgesic upon discharge.5 As
many as 18% of patients surveyed in the ED have severe
pain upon presentation, and 11% may have severe pain
upon discharge.6 Children,7 the elderly,8 and certain
ethnic groups9 are especially prone to oligoanalgesia in
the ED. In one large ED, Hispanic patients were significantly less likely to receive analgesics for long bone
fractures than non-Hispanic patients. Those lucky few
who were treated rarely received parenteral or opioid
agents.9 But why are physicians, who are so expansive in
ordering tests, so miserly in analgesia?
Some physicians believe they must have a firm diagnosis
to treat pain; otherwise, the medication will obscure the
clinical examination. Nowhere is this myth more prevalent than in the evaluation of abdominal pain.
Physicians in training are frequently taught to
withhold analgesics in patients with acute abdominal
pain for fear of missing serious pathology. This dogma
may stem from Zachary Cope’s 1921 monograph. The
good doctor stated, “If morphine be given, it is possible
for a patient to die happy in the belief that he is on the
road to recovery, and in some cases the medical attendant
may for a time be induced to share the delusive hope.”2
This observation (certainly not based on a doubleblinded, randomized, controlled trial) dates to an era in
which advanced diagnostic techniques were not available. Fortunately, the latest edition of this classic surgical
text now advocates reasonable doses of pain medication
for patients with abdominal pain. In a dramatic reversal,
the book now admonishes that withholding of analgesia
is a “cruel practce” (although they imply that only a
“responsible surgeon” should order the drugs).2 Another
case of one step forward and two steps back.
Recent studies suggest that opioid analgesics given
to patients with acute abdominal pain do not alter
diagnostic accuracy or delay surgical therapy. Pace
studied 71 ED patients with acute undifferentiated
abdominal pain and randomized patients to receive
either saline placebo or morphine sulfate.11 The mean
total dose of morphine administered in the experimental
group was 15 mg. The patients who received morphine
reported a greater degree of analgesia than placebo, and
no patient had any serious pathology missed. The
morphine did not mask physical findings such as
peritoneal signs. Other studies have found similar
results, and some suggest that the relief of pain may
actually enhance the examination by reducing anxiety and
increasing patient cooperation.12,13
These studies do not suggest that patients with acute
abdominal pain should be simply medicated and
released, but rather that analgesia be given while the
cause for the pain is investigated.
Analgesia In The ED: Habits And Facts
Several reasons may account for the parsimonious
treatment of pain in the ED. None are compelling. (See
also Table 1.)
Training
The problem of oligoanalgesia begins with medical
training. Pain management is frequently ignored in
medical school and residency; physicians-in-training
copy bad habits from colleagues and mentors. Nurses
too are given inadequate training in assessing and
treating pain.1
Fears Of Drug Dependence
And Anger Toward Addicts
Physicians may have irrational fears of regarding
iatrogenic overdose or addiction. In reality, iatrogenic
overdose is easily avoided by the proper dose of medication in the proper route. Fostering addiction through
emergency pain relief is virtually unheard of. In the
Boston Collaborative survey, nearly 12,000 medical
inpatients were treated with opioid analgesics for acute
pain. Only four patients developed addiction.10
More realistically, emergency physicians are angered
by patients whom they believe to be seeking drugs. While
drug seekers populate every ED, it’s no shame to
occasionally be “duped” into a narcotic prescription by
these desperate (and sometimes innovative) characters.
Certainly, it is better to err on the side of relieving true
pain at the risk of being sporadically fooled by an addict.
Fear Of Side Effects
Analgesics are routinely withheld from patients with the
potential for hemodynamic instability. While this is a
theoretical concern, there’s no evidence to suggest that
carefully titrated doses of analgesics will mask significant
disease or contribute to instability once primary stabilization has occurred. The most recent edition of the American
College of Surgeons’ Advanced Trauma Life Support (ATLS)
course advocates the judicious use of analgesics in the
multiple trauma patient, stating, “The relief of severe
pain is an important part of the management of the
trauma patient.”14
Table 1. Factors Contributing To Inadequate Analgesia
In The ED.
• Inadequate training in analgesic practices
• Over-reliance on anecdotal experience
• Irrational fears of overdosage and addiction
• Focus on diagnostic work-up vs. treatment of symptoms
• Fear of exacerbating hemodynamic instability
• Unfounded concerns of masking intra-abdominal
pathology
• Overly suspicious that everyone with chronic pain is
an addict
Fear Of Voiding Informed Consent
Analgesics are occasionally withheld from certain
patients in whom surgical intervention is needed due to
• Fear of confrontation with consultants
Emergency Medicine Practice
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December 1999
pain. The Agency for Health Care Policy and Research
has published a clinical practice guideline that advocates
this approach.16
Numerical pain rating scales, Likert scales, visual
analog scales, and smiling face scales for children have all
been used effectively to measure pain.2 Serial pain scales
may be recorded on a designated area in the patient’s
chart along with the vital signs. These scales will help the
clinician gauge the response to therapy and use additional agents if necessary.
concerns regarding consent. However, the mere fact that a
patient has been given narcotic analgesia does not render them
incapable of consenting to surgical procedures. Vessey and
Siriwardena surveyed patients who underwent abdominal surgery, and the majority stated that the administration of pre-operative analgesia did not alter their ability
to provide informed consent.15 In fact, withholding
analgesics until consent is obtained may be coercion—a
more serious breech of the physician-patient relationship
than the failure to obtain informed consent.
The safest approach is to use judicious titrated doses
of analgesics to control the pain without excessively
altering cognitive function. If possible, involve the family
in the process of obtaining consent, and document the
patient’s ability to understand the risks and benefits of
the procedure.
Establish Clinical Pathways And Educational
Programs In Pain Management
Clinical pathways for the management of acute pain can
include pain scales, physician and nurse protocols, and
other prompts to treat pain. (See Clinical Pathway on
page 4.) Jones studied the use of a four-hour educational
program on resident analgesic practices in the ED. After
the program, a significantly greater proportion of
patients had clinically important improvements in pain
scores.17 Small enhancements in the ED processes and reeducation of staff are simple steps to enhance analgesia in
the ED.
Fear Of Angering Consultants
Some physicians still feel that analgesics should be
withheld until a diagnosis is established or consent for a
procedure is obtained. This approach is not supported by
the medical literature. Communication with and education of these consultants is essential. These discussions
should lead to interdisciplinary pathways for the use of
analgesics in patients with acute abdominal or other
types of pain.
Choosing Analgesic Agents: The Right Drug,
The Right Route, In The Right Dose
There are numerous means to control pain (see Table 2 on
page 5). The emergency physician should use both
pharmacologic and non-pharmacologic approaches.
When selecting drugs to control pain, the physician
should understand the advantages and disadvantages of
the various agents. Peripheral analgesics such as the
NSAIDs inhibit the synthesis of inflammatory mediators
that stimulate pain fibers or lower the pain threshold.
Centrally acting analgesics such as the opioids modulate
the response of the CNS to a given painful stimulus.
Many oral opioid preparations combine peripheral and
central analgesics to control pain at both sites.
Certain analgesics have advantages in particular
clinical situations. For example, NSAIDs are useful in
dysmenorrhea, since these agents inhibit prostaglandin-
“Pain is real when you get other people to believe in it.
If no one believes in it but you, your pain is madness
or hysteria.” —Naomi Wolf, U.S. author.
The Beauty Myth, “Violence” (1990).56
Improving Pain Management In The ED
Use Pain Scores
In the ED, it is commonplace to measure and recheck
vital signs. In a similar fashion, pain scales measure the
need for and response to analgesic therapy. The physician
and nurse should record the pain score early during the
patient encounter and assess the success or failure of pain
interventions based upon subsequent scores. The first
score may even be obtained at triage. Such a system is
routinely used in many EDs for the treatment of chest
Continued on page 5
Pearls To Improve Pain Management In The ED
(The RELIEF Approach)
• Record the pain score on the patient’s chart before and after treatment.
• Ease the patient’s concerns—often the fear of pain is more distressing than the pain itself. Inform the patient that pain control is a
goal of the ED patient care team.
• Look and listen to the patient—they will be the best judge on how much pain they are having and how much relief they have
obtained.
• Inquire: Always ask the patient if they need pain medication.
• Educate ED staff on proper analgesic techniques.
• Facilitate multi-disciplinary protocols with nursing and other specialties to manage common painful conditions in the ED.
December 1999
3
Emergency Medicine Practice
Clinical Pathway: Recommended ED Analgesia
Assumes hemodynamic stability
In patients with complaint of pain,
complete pain score. Re-assess after
analgesics given. (Class IIa)
Chest pain
Yes
→
Suspect ischemia?
No
→
→
→
Treat as indicated (Class I)
Consider parenteral opioid
or oral NSAID (Class IIa)
Headache
→
Suspect migraine?
No
Yes
→
→
→
Consider specific antimigraine therapy (Class I)
Consider parenteral opioid
(Class IIa)
→
Female pelvic pain
→
Pregnant?
Yes
→
→
No
Consider oral NSAID
(Class IIa)
Abdominal pain
→
Renal colic?
No
→
→
Yes
→
Consider parenteral
fentanyl 1 mcg/kg (Class IIa)
→
Pharyngitis
→
Consider oral or parenteral
analgesic in combination with
steroids (Class IIa)
→
Musculoskeletal pain
→
Consider oral or parenteral
analgesic (Class I)
Severity of pain mild:
Consider acetaminophen.
Severe: Consider opioid.
(Class IIa)
Consider NSAID plus
parenteral opioid (Class IIa)
The evidenc e for recommendations is graded using the
following scale. For complete
definitions, see back page.
Class I: Definitely recommended. Definitive, excellent
evidence provides support.
Class II a: Acceptable and
useful. Very good evidence
provides support. Class II b:
Acceptable and useful. Fair-togood evidence provides
support. Class III: Not
acceptable, not useful, may be
harmful. Indeterminate:
Continuing area of research.
Adapted from Department of Emergency Medicine Pain Management Guidelines, The Mercy Hospital of Pittsburgh. This clinical pathway is
intended to supplement, rather than substitute, professional judgment and may be changed depending upon a patient’s individual needs.
Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright  1999 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants permission to reproduce this
Emergency Medicine Practice tool for institutional use.
Emergency Medicine Practice
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December 1999
Continued from page 3
exist, the opioid analgesics are the most effective drugs for
rapidly controlling pain in the ED. Unfortunately, many
physicians have gross misconceptions about dosing,
irrational fears regarding addiction, and rely upon the
undependable intramuscular route.
mediated cramping. These prostaglandin inhibitors are
also very useful to control the colicky pain of biliary or
ureteral origin.
Pharmacokinetics of the drug are also important. Shortacting agents (such as fentanyl) are best used for the
treatment of painful procedures, while longer-acting agents
(such as oral opioid preparations and NSAIDs) are appropriate for outpatient use. Patients with chronic pain may
benefit from sustained-release products and agents that alter
monoamine reuptake, such as the tricyclic antidepressants.
Although potent analgesics are effective in pain
regardless of etiology, in certain conditions, diagnosticspecific therapy is useful. Examples include nitrates to
treat cardiac ischemia pain, antacids for dyspepsia, and
neuro-modulators or vasoactive agents to treat migraine.
Dosing
The effective dose of an analgesic differs between
individuals, and standard doses or even weight-based
doses may not be appropriate. Generally, lower doses are
required in the elderly, although large individual variability exists. Many clinicians under-dose opioids in the
emergency setting for fear of untoward side effects. In
particular, meperidine (Demerol) is uniformly underdosed. Barsan studied the use of high-dose opioid
analgesia in the emergency setting in which 72 patients
aged 18-63 received 1.5-3.0/kg of meperidine.18 Although
sedation was noted in most patients, none had significant
respiratory depression. In most otherwise healthy ED
patients, use starting doses of approximately 0.1 mg/kg
of morphine or 1.0 mg/kg of meperidine by the intravenous route; titrate additional doses to the desired effect.
However, many patients will require significantly higher
doses to control their pain.
Opioid Analgesics
The ideal analgesic for emergency use would be highly
effective, have rapid onset, be easily used, and titratable.
This fabled agent would have a reliable duration of
action, lack hemodynamic effects, have minimal to no
side effects, and would not mask signs or symptoms of
serious disease. Although this agent obviously does not
Table 2. Mechanisms Of Pain Control.
Mechanism
Therapy
Stimulate opiate receptors in the CNS
Opioid analgesics
Block inflammatory mediators that cause pain or lower pain threshold
NSAIDs
Block pain fiber transmission into the CNS
Local anesthetics
Stimulate descending serotonergic pathways
Tricyclic antidepressants, Tramadol
“Gate closing” at dorsal horn of spinal cord
Transcutaneous electrical nerve stimulation;
acupuncture
Reinterpretation of painful stimulus
Hypnosis; reassurance
Table 3. Opioid Analgesics In Emergency Medicine.
Route
Typical Dose Range†
Frequency†
IV, IM, SQ*
0.1-0.2 mg/kg
q3h
Meperidine
IV, IM, SQ*
1-2 mg/kg
q2h
Fentanyl††
IV, IM, SQ*
1-2 mcg/kg
q1h
Hydrocodone
PO
5-10 mg
q4h
Codeine
PO
30-60 mg
q4h
Oxycodone
PO
5-10 mg
q4h
Propoxyphene
PO
100-200 mg
q6h
Hydromorphone
IV, IM, PO
2-4 mg
q4h
Tramadol
PO
50-10 mg
q6h
Drug
Morphine sulfate††
††
* IV preferred. When not possible or practical, SQ preferred over IM.
† The appropriate amount and timing of opioids vary widely between individuals. IV opioids should be titrated to pain.
The additional doses are given at fixed intervals only after pain is under control.
†† Dosages for these analgesics apply to both adult and pediatric patients.
December 1999
5
Emergency Medicine Practice
Route Of Administration
Specific Agents
Opioid analgesics may be given by virtually any route,
including oral, intramuscular, subcutaneous, intravenous,
intrathecal, intranasal, rectal, and transdermal. In the ED,
many clinicians over-rely on the intramuscular route. The
major disadvantages of this mode of administration are
its erratic absorption (resulting in unreliable onset/
duration) and the pain of administration. The intramuscular route is especially unpredictable in patients with
hypovolemia or third spacing, such as patients with
blood loss or those with large burns. Conversely, intravenous administration of opioid analgesics results in
reliable onset and duration, allowing individualized
titration. If intravenous access is difficult, use subcutaneous
administration, which is effective and less painful than the
intramuscular route. Here again, patients with peripheral
vasoconstriction, such as those with hypovolemia, may
have delayed or variable responses.
There are several opioid analgesics available, for both
oral and parenteral administration (see Table 3 on page
5). Fortunately, these highly effective agents are quite
inexpensive (see Table 4).
Parenteral Opioid Analgesics
Morphine sulfate is the analgesic to which all others
are compared. Despite certain agents having a higher
potency per unit weight, all parenteral agents will be
equianalgesic at properly used doses. The major advantages to morphine are its low cost and its half-life of
3-4 hours—longer than most other parenteral agents.
The major disadvantage to morphine is its potential to
release histamine, resulting in vasodilation or localized
inflammatory reactions. Surgical legend suggests that it
not be used in patients with suspected biliary disease
because it may increase intrabiliary pressures. This
concern is entirely theoretical—based solely on in vitro
studies. In addition to sedation and respiratory depression in high doses, other common side effects include
nausea and dysphoria.
Many clinicians use meperidine in the ED, primarily
out of habit. Meperidine has several disadvantages
compared to morphine. Meperidine has a shorter
duration of action, and it is metabolized to
normeperidine. Normeperidine may cause CNS side
effects such as disorientation, hallucinations, and can
lower the seizure threshold, particularly in patients with
renal failure or sickle cell disease.20 Meperidine may
cause dangerous depressive or excitatory reactions such
as hyperpyrexia, hyper- or hypotension, and coma when
given with certain psychotropic agents, particularly the
monoamine oxidase inhibitors (MAOIs).
Fentanyl has several advantages in the ED. It is
short-acting, and therefore useful in procedural sedation
or in patients who require serial examinations. It causes
little histamine release and no significant myocardial
depression; therefore, it is safer than many other opioids
when used in patients at risk for hemodynamic instability. In higher doses, it may cause apnea before sedation.
Fentanyl can cause muscular rigidity when given by the
parenteral route. However, this typically occurs with
rapid administration at the very high doses used for
induction of anesthesia (10 mcg/kg or more).
The narcotic agonist-antagonist analgesics (see
Table 5 on page 8) stimulate opioid receptors but have
certain antagonist properties. This prevents respiratory
depression despite high dosage. They also cause less
sedation and euphoria than direct opioid agonists.
However, due to their antagonist properties, they should
not be used in opioid-dependent patients, as they may
cause withdrawal.
Agonists-antagonists have a high rate of side
effects—butorphanol in some migraine studies had so
many adverse effects that 60% of patients would not use
it again. In one study, the most common side effects,
compared to placebo, were dizziness (58% vs 4%), nausea
Timing
Clinicians also tend to prescribe these drugs on a “PRN”
basis. However, more sustained analgesia occurs with
“round-the-clock” dosing. This is presumably due to
sustained plasma levels. Therefore, in patients with
moderate to severe pain, prescribe outpatient analgesics
on a regular basis based on the pharmacokinetics of the
particular drug, rather than “PRN.”
PCA pumps
Patients who self-administer small opioid doses are able
to control pain with fewer side effects than patients
whose medication schedule is determined by a physician.
This enhanced sense of personal control will also reduce
anxiety and improve analgesia.19
PCA pumps allow patients to self-titrate opioids; in
some hospitals, they are ubiquitous in postoperative and
oncology wards. However, these pumps are rarely seen in
the ED. Barriers to their use include equipment cost and
maintenance, lack of familiarity, and pharmacy charges
for filling the syringes. Nevertheless, the numerous
advantages of the PCA pump make it likely that these
devices will play a larger role in ED pain management in
the coming decade, especially for patients who may have
a prolonged ED stay.
Table 4. Pharmacy Cost Of Selected Parenteral Opioid
Analgesics (Single Dose).
Drug
Cost*
Morphine 10 mg tubex
$0.46
Meperidine 100 mg tubex
$0.38
Fentanyl 100 mcg ampule
$0.21
Hydromorphone 4 mg ampule
$0.59
Nalbuphine 10 mg ampule
$0.28
* These prices reflect pharmacy costs only; patient charges
may vary.
Emergency Medicine Practice
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December 1999
lower dose of opioids) or to prophylactically treat opioidinduced nausea or vomiting. Hydroxyzine appears to
have mild analgesic activity at very high doses (75-100
mg) when combined with opioid analgesics. These doses,
which are much higher than typically used, can produce
significant sedation and respiratory depression. The dose
commonly used (50 mg) has no “opioid-sparing” effect but
merely increases the cost of analgesia by 30-38%.22 In addition
to the extra cost, hydroxyzine must be given by the
painful intramuscular route (adding injury to insult).
Promethazine (Phenergan) has an anti-analgesic
effect and should not be used routinely.23 Since opioidinduced nausea is not universal, employ these agents as
and/or vomiting (38% vs 18%), and drowsiness (29% vs
0%).21 Most of these agents (particularly pentazocine)
have affinity for the sigma opiate receptor, which may
result in dysphoria, disorientation, hallucinations, and
panic. Reports of abuse of the intranasal preparation
led butorphanol to be classified as a DEA schedule IV
drug in 1997.
Opiates And Antiemetics
Many clinicians routinely prescribe antiemetics such as
hydroxyzine (Vistaril) or promethazine (Phenergan) with
opioid analgesics. This combination is selected for either
a purported synergistic effect (supposedly requiring a
Top 10 Myths Regarding Pain Management In The ED
pain to be uncontrolled.
Myth #1:
Analgesics should not be given to patients with
acute abdominal pain, as they may mask the signs
of serious disease.
Fact:
In controlled studies, analgesics do not alter the ability to
diagnose the cause of undifferentiated abdominal pain,
and they may even improve diagnostic accuracy.
Myth #6:
The appropriate parenteral dose of meperidine (Demerol) is
50-75 mg.
Fact:
The effective dose can vary widely, and most patients will
require at least 1.5 mg/kg.
Myth #7:
Meperidine (Demerol) is better than morphine in patients
with suspected biliary colic.
Fact:
The increase in intrabiliary pressure is similar with
meperidine and morphine. More importantly, it is of no
clinical significance.
Myth #2:
Always give antiemetics such as Phenergan or Vistaril with
opioid analgesics to enhance the analgesic effect.
Fact:
Antiemetics do not enhance the analgesic effects of opioids
at the commonly used doses.
Myth #3:
Ketorolac is the strongest NSAID, so it is best for severe
pain.
Fact:
There is no evidence that any NSAID provides any better
analgesia than another. The analgesic effect from
ketorolac is similar to other NSAIDs.
Myth #8:
All patients requesting pain medications in the ED are
drug abusers.
Fact:
Opioid analgesics can be an important part of pain
management in patients with chronic or recurrent
pain syndromes.
Myth #4:
Acetaminophen with codeine is the first choice for an oral
narcotic analgesic.
Fact:
Codeine has limited utility due to its low potency and
frequent side effects.
Myth #9:
Prescriptions for opioid analgesics should be avoided due
to the risk of addiction.
Fact:
When they’re prescribed in short courses to treat acute
pain, iatrogenic addiction is a rare phenomenon.
Myth #5:
Pain medications should be prescribed “PRN.”
Myth #10:
Tramadol is useful in treating acute pain.
Fact:
In most studies, the analgesic effect of tramadol is
equivalent or only slightly better than placebo.
Fact:
It is more effective to give pain medication on a
regular dosing schedule rather than waiting for the
December 1999
7
Emergency Medicine Practice
(10 mg or more), and they may develop seizures that are
difficult to control. Avoid using propoxyphene unless the
patient has demonstrated prior success with this drug.
Oxycodone is an excellent analgesic available alone
or in combination with aspirin (Percodan) or acetaminophen (Tylox, Percocet, Roxicet). It may produce more
euphoria than other oral opioid analgesics and may have
a higher abuse potential. Consequently, it is a DEA
schedule II drug.
Hydromorphone (Dilaudid) is also an effective
analgesic that may be given at similar doses both
orally and parenterally. Like oxycodone, many believe
it has a higher abuse potential, and it is a schedule II
drug. The illegal street value in some cities may be more
than $60 a pill.28
Hydromorphone is useful in patients with sustained
pain (such as cancer pain). Because hydromorphone
is not available as a combination product, the use of
higher doses is not associated with acetaminophen or
aspirin toxicity.
Tramadol (Ultram) has weak opioid receptor agonist
properties and inhibits serotonin and norepinephrine
reuptake in the CNS. Consequently, it is sometimes used
as an adjunct to treat chronic pain. Clinicians who use
this drug to treat acute pain face disappointing results.
Comparative studies in acute pain show tramadol only as
effective as placebo,29 and less effective than hydrocodone
with acetaminophen.30 In addition, it has a high CNS and
gastrointestinal side-effect profile—the manufacturer
reports that within the first week of use, 26% of patients
experience dizziness, 24% nausea, 24% constipation, 18%
headache, and 16% somnolence. Still, abuse of this drug
has been reported. It should not be routinely used to treat
acute pain in the ED, since other, more effective agents
are available.
The outpatient prices of selected opioid analgesics
are listed in Table 6 on page 9.
needed in symptomatic patients.
Oral Opioid Analgesics
The oral opioid analgesics are typically combined with
peripheral analgesics such as aspirin, acetaminophen, or
ibuprofen to treat pain both centrally and peripherally.
This allows for a lower dose of each agent and decreased
side effects.
Codeine has been used for many years, and its
familiarity has resulted in continued use. However,
codeine has many disadvantages. Its analgesic effects are
minimal at the typically used doses, while higher doses
are associated with a lofty incidence of gastrointestinal
and CNS side effects. Seven to 10 percent of Caucasian
patients may not respond to the analgesic effects of
codeine due to a genetically mediated inability to
metabolize codeine to morphine.24 A meta-analysis of 24
studies comparing acetaminophen with and without
codeine found the analgesic effects of the combination to
be only slightly better than the acetaminophen alone.
However, acetaminophen with codeine had a much
higher incidence of side effects, such as nausea, vomiting,
and sedation.25
Hydrocodone is available alone or in combination
with either acetaminophen (Vicodin, Lorcet) or ibuprofen
(Vicoprofen). Hydrocodone is better tolerated and more
effective than codeine; in one randomized, double-blind
clinical trial, CNS side effects were significantly lower
with hydrocodone, and patient satisfaction was greater.26
Propoxyphene (Darvon, Darvocet) is a weak analgesic, but sedation is common. A recent meta-analysis of 26
randomized trials comparing propoxyphene-acetaminophen combination products to acetaminophen concluded that propoxyphene was no more effective than
acetaminophen alone. Furthermore, the combination was
associated with more dizziness and drowsiness.27
This drug is particularly dangerous in overdose.
Patients with propoxyphene overdose may present
without the classic pinpoint pupils of the narcotic
toxidrome. They have notable sedation and respiratory
depression requiring high doses of naloxone for reversal
Nitrous Oxide
Nitrous oxide has great potential in the ED. It is easy to
administer, has a rapid onset, a short duration of action,
Table 5. Narcotic Agonist/Antagonist Analgesics.
Drug
Dose
Route(s)
Frequency
Pentazocine (Talwin)
12.5/325 mg ASA
PO
q4-6h
(Talacen)
25 mg/650 mg APAP
PO
(Talwin Nx)
50 mg/0.5 mg naloxone
PO
Nalbuphine (Nubain)
10-20 mg
IV/IM/SQ
q3-4h
Butorphanol (Stadol)
1-2 mg
IV/IM/SC/ Intranasal
q3-4h
Buprenorphine (Buprenex)
0.3-0.6 mg
IV/IM/SQ
q4-6h
Dezocine (Dalgan)
10-20 mg
IV/IM/SQ
q3-4h
Emergency Medicine Practice
8
December 1999
renal failure, and anaphylactoid reactions may be severe,
life-threatening, and difficult to treat. Peptic ulcer disease
may occur after treatment with any NSAID, but the risk
appears lowest with ibuprofen.32
Most patients in the ED with mild-to-moderate pain
are candidates for an oral NSAID or acetaminophen.
More severe pain mandates the use of titrated opioids.
Avoid NSAIDs in patients at high risk for side effects,
such as the elderly, those with peptic ulcer disease, renal
failure or known hypersensitivity. In such patients,
treatment with opioids is preferred.
provides both sedation and analgesia, and has minimal
cardiovascular effects. Because the 50/50 mixture of
nitrogen and oxygen is not very effective in severe to
moderate pain, some authorities recommend the 70/30
mixture. Be aware that the gas becomes less effective as
altitude increases due to decrease in partial pressures.
Nitrous oxide-oxygen mixtures with attached
scavenging devices are commercially available for
ED and prehospital use. These devices use a patientheld valve as fail-safe mechanism. If the patient
becomes excessively sedated, the mask falls away and
the patient recovers. Nitrous oxide should not be used
in conditions in which the gas may expand, such as
pneumothoraces, small bowel obstructions, air embolism,
and decompression sickness. It is contraindicated in the
first trimester of pregnancy due to the potential for
teratogenic effects.
Parenteral NSAIDs
Ketorolac is the only NSAID available for parenteral
administration in the United States. Initial studies
comparing ketorolac to opioids showed equianalgesia in
postoperative pain and renal colic. However, these
studies did not account for the variability in opioid
dosing or titratability of opioids to enhance analgesia,
thus biasing the results in favor of ketorolac.33 Like other
NSAIDs, ketorolac is useful in prostaglandin-mediated
pain syndromes, such as postoperative pain, renal colic,
and biliary colic.
There is no evidence to suggest that ketorolac is
more potent than the other NSAIDs. Several ED studies
have compared ketorolac to oral NSAIDs in acute pain.
The less expensive oral agents have the same effect on
pain control as parenteral ketorolac.34-36 Furthermore,
parenteral administration of NSAIDs does not offer
enhanced potency over oral administration.37,38 As with
other NSAIDs, adverse effects such as gastrointestinal
bleeding, renal dysfunction and platelet inhibition may
occur, even with single doses. Ketorolac is also quite
expensive: the cost to the pharmacist for a 60 mg tubex is
$6.70 and each 10 mg tablet is $1.07, while 800 mg of
generic ibuprofen costs $0.04. Therefore, use ketorolac
only in conditions where prostaglandin inhibition is
needed to control pain and the patient is unable to
tolerate oral NSAIDs (such as biliary or renal colic with
vomiting). The maximum intravenous dose is 30 mg, half
the maximum intramuscular dose.
Non-narcotic Analgesics
The non-narcotic analgesics consist of those with
prostaglandin inhibitory properties (NSAIDs and
COX-2 inhibitors) and acetaminophen. Prostaglandinmediated pain is frequent in the ED and includes ureteral
colic, biliary colic, and dysmenorrhea. These conditions
are particularly suited for treatment with NSAIDs.
NSAIDs may be used alone or in conjunction with an
opioid. They are widely available and are not associated
with dependence, tolerance, or significant respiratory
depression or sedation.
Unlike the opioids, in which escalating doses
increase analgesic effects (in addition to side effects),
non-narcotic analgesics have a therapeutic “ceiling.”
However, chronic inflammatory conditions such as
rheumatoid arthritis require higher-than-typical analgesic
doses. Although the NSAIDs differ in pharmacokinetics
and their ability to inhibit prostaglandin synthesis, there
is no evidence to suggest that any one NSAID is more
effective than another. However, for unclear reasons,
certain patients may respond better to one class of
NSAID vs. another.31
The NSAIDs have certain disadvantages. Dyspepsia
is common. NSAID-associated gastrointestinal bleeding,
COX-2 Inhibitors
NSAIDs inhibit the enzyme cyclooxygenase (COX),
which is required to synthesize prostaglandins. There are
two isoforms, both of which are blocked by NSAIDs:
COX-1 appears to be gastro-protective and is found in
platelets, and COX-2 is induced at sites of inflammation.
Recently, selective COX-2 inhibitors were developed to
provide antiprostaglandin activity without the adverse
effects on gastric mucosa and platelets. Celecoxib
(Celebrex) was the first of these agents approved by the
FDA. It is marketed for the treatment of osteoarthritis
and rheumatoid arthritis.
While it would seem that these agents could also
treat acute pain with fewer adverse consequences,
scientific support is lacking. In the single-dose trials with
post-dental procedure pain, celecoxib was less effective
than naproxen, while in post-surgical pain, it was no
Table 6. Retail Prices Of Selected Oral Opioid Analgesics
(15 Tablets).
Drug
DEA Schedule
Price
APAP—codeine (generic)
III
$7.00
Hydrocodone (generic)
III
$7.00
Oxycodone (generic)
II
$7.00
Tylenol #3 (brand name)
III
$8.00
Vicodin 5 mg
III
$8.00
Percocet
II
$8.00
Talwin-Nx
IV
$14.00
Dilaudid 4 mg
II
$15.00
Ultram 50 mg
-
$23.00
Stadol NS
IV
$64.00
December 1999
9
Emergency Medicine Practice
better than placebo.39 Rofecoxib (Vioxx) has comparable
efficacy to 400 mg ibuprofen in post-dental surgery
pain.40 Although professed to lower the risk of gastrointestinal bleeding, clinically significant gastric
bleeding has followed use of this drug.41 Its safety profile
in doses required to treat acute pain is yet to be determined. It costs approximately $4.85 per 50 mg dose, as
compared to $0.04 for 800 mg ibuprofen. Currently, there
is no evidence to support the routine use of COX-2 inhibitors
in the treatment of acute pain.
appropriate doses of OTC NSAIDs whenever feasible. In
order to reduce the risk of renal failure and GI hemorrhage, suggest or prescribe a maximum supply of five
days, since the risk of these complications appears to
increase after five days of use.
Skeletal Muscle Relaxants
Muscle relaxants are often used for myofascial strains;
however, their major benefit may come from their
sedative effects. Despite their suggestive name, there is
no conclusive evidence that they relax skeletal muscle.42
In comparative studies, patients who received skeletal
muscle relaxants reported greater analgesia vs. placebo.43,44 However, no particular agent is more effective
than another.
Cost And Duration Of Therapy
The retail prices of nonnarcotic analgesics varies widely
(see Table 7), and over-the-counter (OTC) agents are
typically much less expensive than prescription agents.
For example, two 200 mg OTC generic ibuprofen tablets
cost far less than a single 400 mg generic ibuprofen by
prescription. Since there are no proven differences in
efficacy between NSAIDs, instruct patients to use
Local Anesthetics
In the ED, painful procedures such as laceration repair,
nasogastric intubation, Foley catheter placement, joint
reduction, and arterial and venous cannulation are
frequently performed (see Table 8). The proper use
of local anesthetics, either by direct infiltration, nerve
block (see Table 9), field block, or intra-articular use can
render these procedures painless. Always document
distal neurologic function before performing local or
regional anesthesia.
In addition, local anesthetics can treat the pain of
corneal abrasion so an adequate examination can be
performed. Local anesthesia provide sustained pain relief
in dentalgia using various nerve blocks.
Femoral nerve blocks are an excellent means to
Table 7. Retail Price Of Selected NSAIDs (Five-Day Supply).
Drug/dose
Quantity
Price
Aspirin 325 mg
40
$1.52
Ibuprofen 200 m (OTC)
40
$2.71
Naproxen 220 mg (OTC)
30
$3.11
Ibuprofen 400 mg
20
$7.00
Ibuprofen 800 mg
15
$7.00
Indomethacin 50 mg
15
$7.00
Naproxen 375 mg (generic)
15
$11.00
Relafen (nabumetone) 500 mg
10
$15.00
Naprosyn 375 mg
15
$21.00
Toradol 10 mg
20
$33.00
Table 9. Common Nerve Blocks In The ED.
Extremities
Fingers: Digital block
Fingers/Metacarpals: Metacarpal block
Table 8. Uses For Local Anesthetics In The ED.
Hand: Ulnar, radial, median block
Procedures:
Femur/anterior thigh: Femoral block
Wound repair
Foot: Saphenous, superficial peroneal, deep peroneal, sural,
tibial blocks
Thoracostomy
Abscess drainage
Arthrocentesis
Intraoral
Lumbar puncture
Upper lip/lateral nose: Infraorbital block
Nasogastric intubation
Lower lip/chin: Mental block
Nasotracheal intubation
Arterial blood gases
Mandibular teeth, anterior 2/3 of tongue: Inferior alveolar
block
Venous cannulation
Individual teeth: Periapical block
Foley catheter placement
Epistaxis management
Other areas
Joint reduction
Frontal scalp: Supraorbital block
Occipital scalp: Greater and lesser occipital block
Symptom relief:
Penis: Dorsal penile block
Dentalgia
Vulva/Vagina: Pudendal block
Corneal abrasions
Ribs: Intercostal blocks
Emergency Medicine Practice
10
December 1999
it will not change the neurologic examination in the leg
below the knee.
control the agony of a femur fracture without the need
for high doses of parenteral opioids.45,46 This type of block
is particularly useful in multiple-trauma victims or
in children. It should be performed after a detailed
neurovascular examination of the lower extremity.
Approach the femoral nerve lateral to the femoral
artery at the inguinal crease. A dose of 5-10 cc of a
long-acting local anesthetic such as bupivacaine will
provide hours of relief. Although this block will temporarily affect the motor and sensory function of the thigh,
Pain Of Injection
Some patients report an allergy to local anesthetics, but
true allergy to amide local anesthetics is rare; many
patients who report allergy may have had an adverse
effect to the preservative or received an inappropriately
high dose. The major adverse effect of local anesthetics is
the pain of administration. This can be minimized by
Ten Excuses That Don’t Work In Court
6. “I didn’t know that Demerol interacted with Nardil.”
This deadly drug interaction occurred in the highly
publicized Libby Zion case. A fatal hyperpyrexic reaction
can occur with this drug combination, presumably due to
inhibition of serotonin reuptake.
1. “He got better after the Demerol. How was I supposed
to know he had a subarachnoid hemorrhage?”
Although controlling pain is a desirable goal, it must
not be the only goal. Pain control does not preclude
evaluation to rule out serious pathology. Opioid analgesia
will relieve the pain of even life-threatening conditions
such as subarachnoid hemorrhage and pulmonary
embolism. Just because the pain is gone does not mean
the patient is “fine.”
7. “I forgot to note he was numb in his fingers before I
did the median block.”
Always document prior neurologic status before using
local anesthetics, particularly for regional anesthesia.
2. “Micrograms, milligrams—what’s the difference?”
The difference is life and breath in the case of fentanyl. A
100 mg dose led to apnea in this patient.
8. “I didn’t realize I was in the artery when I injected
the lidocaine.”
When performing nerve blocks or using local anesthetics,
aspirate before injecting, or continuously move the needle
in and out. This will prevent intravascular injection. Ensure
that infiltration does not occur and that the maximum dose
is not exceeded, so toxicity does not develop.
3. “She never said she was allergic to Percodan—just
to aspirin.”
This patient was most upset about the emergency
cricothyroidotomy performed after she arrested. While true
allergy to the opioid component of combination products
is uncommon, certain patients may have allergies to the
non-narcotic component.
9. “We had already reduced the shoulder—it took 15
minutes of tugging and straining under conscious
sedation. The procedure was over so I told the nurse she
could take him off the pulse oximeter.”
The several minutes after a procedure may be the most
dangerous. During painful stimulation, the patient is
unlikely to stop breathing (unless the physician is
performing unconscious sedation). When a patient is heavily
sedated for an especially painful procedure, apnea may
occur when the stimulus is removed. Cardiorespiratory
monitoring should continue until the patient is arousable
to verbal commands.
4. “I didn’t think a three-week supply of indomethacin
would be a problem for Mrs. Viejo. She bled down to a
hemoglobin of what???”
Four. Life-threatening complications of NSAID use increase
in frequency after 5-7 days of use. The elderly are
particularly prone to gastrointestinal hemorrhage from
these agents. The bleeding is often painless.
5. “I was going to check his pressure before giving 15 mg
of IM morphine. But he was in a lot of pain from that
leaking aneurysm.”
Opioid analgesics have vasodilatory effects and may blunt
the secretion of catecholamines. In the patient with
potential hemodynamic instability, use only small
intravenous doses and balance pain control with clinical
effects. Patients who are overtly hypotensive require
intravenous fluids and other stabilizing measures before
giving opioids.
December 1999
10. “I didn’t know he was driving home after we gave him
the morphine. I was shocked when I saw him in the trauma
room an hour later.”
I’ll bet you were also shocked by the lawsuit. Patients who
receive opioids or other sedative agents in the ED should not
drive home. Give them verbal and written instructions before
leaving the ED, warning them not to drive or operate power
tools while under the influence of these medications.
11
Emergency Medicine Practice
of these dangers, and the abuse potential of a cocainebased drug, TAC use is disappearing in most EDs.
Instead, a solution of lidocaine 4%, epinephrine
1:2000, and tetracaine 1% (LET) is as effective and less
expensive ($3 vs $35 for TAC).53 EMLA cream (lidocaineprilocaine emulsion) is useful for anesthetizing the skin
before venipuncture and may anesthetize wounds.
However, its utility in the ED is limited, since it typically
using buffered solution, warming, and injecting slowly
with a long, narrow-gauge needle.47-49 (See Table 10.) The
rate of administration has the greatest effect on reducing
the pain of infiltration, followed by buffering and
warming, respectively.
Topical Anesthetics
Since there are many indications for local and topical
anesthetics in the ED, and they are relatively simple to
use, employ them routinely for procedures listed in Table
11 on page 13. Topical lidocaine may be used alone to
anesthetize the mucosa in procedures such as nasogastric
tube insertion and Foley catheter insertion, or combined
with a topical sympathomimetic such as phenylephrine
for cauterization of anterior epistaxis. As with infiltration
of local anesthetics, wait at least five minutes after the
application before beginning the procedure. Both
proparacaine and tetracaine may be used in the eye, but
proparacaine may be less painful to instill.50
A solution of topical tetracaine 0.5%, epinephrine
1:2000 and cocaine 10.4% (TAC) will effectively and
painlessly anesthetize wounds of the scalp and face.
However, TAC can cause seizures or even death in
children if they leak onto mucous membranes.51,52 Because
Table 10. Tips On Using Local Anesthetics For Infiltration.
Methods to Render Solution Less Painful
Warming (to 37˚C)
Buffering (1 mL of 1 meq/mL NaHCO3 in 10 mL of
1% lidocaine)
Lower concentration
Methods to Render Infiltration Less Painful
Long, narrow-gauge needle
Slow infiltration
Subcutaneous infiltration
Counterirritation
Cost-Effective Strategies In Pain Management
1. Use oral rather than parenteral NSAIDs when indicated.
Oral NSAIDs are as effective in controlling pain as intravenous
or IM ketorolac (Toradol). The parenteral formulation is
indicated when the patient is vomiting or otherwise unable
to take PO. The pharmacy cost of ketorolac is more than 100
times that of a generic ibuprofen, not to mention the cost of
an IV or the needle-stick risks associated with IM injections.
Risk Management Caveat: Many patients with renal or biliary
colic may be vomiting or intolerant of PO medications.
nausea, or develops it after the opioid, an antiemetic may
be helpful.
4. Use morphine.
Morphine is an outstanding analgesic. It is potent, safe, and
predictable. From a cost-effective perspective, it is almost
free. Morphine is far less expensive than any other opioid.
Risk Management Caveat: Rare patients have dysphoric
reactions to morphine. Ask patients if they have ever
received it in the past and determine any prior side effects.
2. Recommend over-the-counter NSAIDs instead of writing
a prescription.
OTC NSAIDs such as ibuprofen (Advil, Nuprin, etc.) or
naproxen (Aleve) cost far less than their prescription
counterparts, even accounting for the need to take several
OTC pills to equal a single prescription tablet.
Risk Management Caveat: Patients who come to an ED for
pain may expect or insist upon a prescription. (“You mean I
could have stayed home and taken some Tylenol instead of
coming down here and waiting four hours!?” )
5. Remember the simple things.
Simple, non-pharmacologic interventions can profoundly
decrease pain—and cost little or nothing. Ice, elevation, and
splinting early in the ED stay can provide enormous relief for
a patient with soft-tissue or skeletal injury. Reassure the
patient and let him or her know that you will take care of
their pain. Fear of remaining in pain and the anxiety
associated with anticipation of further suffering can only
decrease the patient’s distress. Tell the patient we have more
drugs than they have pain.55 In pain management, talk is
cheap (but valuable!).
Risk Management Caveat: Reassurance and a kind
demeanor alone cannot relieve the torment of renal
colic. For patients in moderate-to-severe pain,
pharmacologic relief is usually required in addition to
non-drug interventions.
3. When giving opioids for pain control, avoid routine use
of Vistaril (hydroxyzine) or Phenergan (promethazine).
These medications significantly increase the cost of pain
relief and provide no routine benefit. Promethazine may
actually decrease the efficacy of the opioid.
Risk Management Caveat: If the patient has significant
Emergency Medicine Practice
12
December 1999
movement. Radiolucent splints applied before obtaining
x-rays can relieve the unnecessary suffering that comes
with radiographic positioning.
Manipulative therapy is an example of a physical
technique used to relieve musculoskeletal pain. The
ancient art of acupuncture may relieve pain by stimulating inhibitory fibers that attenuate pain fiber transmission into the CNS. Similarly, transcutaneous electrical
nerve stimulation (TENS) and percutaneous electrical
takes 45-60 minutes for full effect. In addition, the cost of
each application is approximately $20.
Non-pharmacologic Therapy Of Acute Pain
Although physicians traditionally use drugs to treat pain,
we must not overlook the non-pharmacologic interventions. Simple interventions include ice and elevation for
soft-tissue injuries and fractures. Immobilization of
fractures can profoundly decrease pain associated with
Table 11. Topical Anesthetics.
Drug
Use on mucous membranes
Use in laceration repair
Lidocaine jelly 2%
+
_
Benzocaine 20%
+
_
TAC (tetracaine, adrenaline, cocaine)
_
+
LET (lidocaine, epinephrine, tetracaine)
_
+
EMLA
_
+
Tool 1. Sample Discharge Instructions For Patients Who Have Received Sedatives
Or Opioid Pain Medicine.
Copyright  1999 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants permission to reproduce this
Emergency Medicine Practice tool for institutional use.
You (or your child) have received a medicine that can cause a person to be sleepy or clumsy. You or your child
must be extra careful in the next several hours. If you have any questions, call the Emergency Department at
(_____) ___________.
The following things are very important:
Children
1.
2.
3.
4.
5.
6.
7.
No eating or drinking for the next two hours. If your child is an infant, they may be fed half their normal
feeding one hour after discharge.
If sleepy, children should be awakened from sleep every hour for the next four hours.
No play that requires coordination, such as bike riding, skating, swing sets, or climbing, for the next 24 hours.
No playing for the next 24 hours without an adult to watch them.
Return to the Emergency Department IMMEDIATELY for vomiting more than once, excessive sleepiness,
trouble breathing, strange behavior, or any worrisome symptoms.
No swimming, baths, showers, or hot objects (curling irons, etc.) for the next 24 hours, without an adult to
watch them.
Your child should eat liquids and light foods to start, then increase as tolerated.
Adults
1.
2.
3.
4.
5.
6.
7.
Do not drive, operate machinery, use power tools, cook, climb, or ride a bicycle for the next 24 hours. Go
directly home, rest inside, watch TV or sleep.
Do not do any activity in which dizziness or sleepiness would be dangerous.
No alcohol for 24 hours. No nonprescription drugs except acetaminophen (Tylenol), aspirin, or ibuprofen
(Advil, Nuprin).
Eat liquids and light foods to start, then increase as tolerated.
Have a responsible person with you at all times for the next 24 hours.
No swimming, no taking baths (showers okay).
Return to the Emergency Department IMMEDIATELY for vomiting more than once, excessive sleepiness,
trouble breathing, strange behavior, or any worrisome symptoms.
Remember that the emergency department is open 24 hours a day, every day, and we are always glad to see you.
December 1999
13
Emergency Medicine Practice
references cited in the paper, as determined by the
authors, will be noted by an asterisk (*) next to the
number of the reference.
nerve stimulation (PENS) will diminish musculoskeletal
pain by this mechanism.
“It is by poultices, not by words, that pain is ended,
although pain is by words both eased and diminished.”
—Petrarch Letter to Guido Sette, 1359.54
1.
Walsh M. Pain and anxiety in A & E attenders. Nursing Stand 1993;7:
40-42. (Article; 200 patients)
2. Silen W, revised by. Cope’s Early Diagnosis of the Acute Abdomen, ed 19.
New York: Oxford University Press; 1996. (Book)
*3. Wilson JE, Pendleton JM. Oligoanalgesia in the emergency department. Am J Emerg Med 1989;7:620-623. (Retrospective; 198 patients)
4. Ducharme J, Barber C. A prospective blinded study on emergency pain
assessment and therapy. J Emerg Med 1995;13:571-575. (Prospective,
blinded; 42 patients)
5. Ngai B, Ducharme J. Documented use of analgesics in the emergency
department and upon release of patients with extremity fractures. Acad
Emerg Med 1997;4:1176-1178. (Letter)
6. Johnston CC, Gagnon AJ, Fullerton L, et al. One week survey of pain
intensity on admission to and discharge from the emergency
department. J Emerg Med 1998;16:377-382. (Pilot study—all patients at
two university hospitals, 1 general and 1 pediatric)
7. Selbst SM, Clark M. Analgesic use in the emergency department. Ann
Emerg Med 1990;1010-1013. (Retrospective; 268 patients)
8. Jones JS, Johnson K, McNinch M. Age as a risk factor for inadequate
emergency department analgesia. Am J Emerg Med 1996; 157-160.
(Retrospective; 231 patients)
9. Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for
inadequate emergency department analgesia. JAMA 1993;269:15371539. (Retrospective; 139 patients)
10. Porter J, Jick H. Addiction rare in patients treated with narcotics. N
Engl J Med 1980;302:123. (Letter)
*11. Pace S. Intravenous morphine for early pain relief in patients with
acute abdominal pain. Acad Emerg Med 1996;3:1086-1092. (Prospective;
71 patients)
12. Attard AR, Corlett MJ, Kidner NJ, et al. Safety of early pain relief for
acute abdominal pain. BMJ 1992;305:554-556. (Prospective, randomized, placebo-controlled; 100 patients)
13. LoVecchio F, Oster N, Sturmann K, et al. The use of analgesics in
patients with acute abdominal pain. J Emerg Med 1997;15:775-779.
(Prospective; 48 patients)
14. Subcommittee on Advanced Trauma Life Support, Committee of
Trauma, American College of Surgeons: Advanced Trauma Life
Support for Doctors Student Manual. Chicago: American College of
Surgeons; 1997. (Book)
15. Vessey W, Siriwardena A. Informed consent in patients with acute
abdominal pain. Br J Surg 1998;85:1278-1280. (Prospective; 49 patients)
*16. Acute Pain Management Guideline Panel: Acute Pain Management:
Operative or Medical Procedures and Trauma. AHCPR Pub. No. 920032. Rockville, MD: Agency for Health Care Policy and Research,
Public Health Service, U.S. Department of Health and Human
Services. Feb. 1992. (Review)
17. Jones JB. Assessment of pain management skills in emergency
medicine residents: The role of a pain education program. J Emerg Med
1999;17:349-354. (Prospective; 126 patients)
*18. Barsan W. Safety assessment of high-dose narcotic analgesia for
emergency department procedures. Ann Emerg Med 1993;22:1444-1449.
(Prospective; 5 EDs, all patients)
19. Portenoy RK. Clinical application of opioid analgesics. In: Sinatra RS,
Hord AH, Ginsberg B, Preble LM, eds. Acute Pain: Mechanisms and
Management. St. Louis: Mosby Year Book; 1992:93-101.
20. Clark RF. Meperidine: Therapeutic use and toxicity. J Emerg Med
1995;13:797-802. (Review of controlled trials)
21. Hoffert MJ, Couch JR, Diamond S, et al. Transnasal butorphanol in the
treatment of acute migraine. Headache 1995;35(2):65-69.
22. Glazier HS. Potentiation of pain relief with hydroxyzine: A therapeutic
myth? Ann Pharmacother 1990;24:484-488. (Review)
23. McGee JL, Alexander MR. Phenothiazine analgesia—fact or fantasy?
Am J Hosp Pharm 1979;36(5):633-640. (Review)
24. Eckhardt K, Li S, Ammon S, et al. Same incidence of adverse drug
events after codeine administration irrespective of the genetically
determined differences in morphine formation. Pain 1998 May;76(12):27-33. (Double-blind study)
25. de Craen AJ, DiGiulio G, Lampe-Shoenmaeckers JE, et al. Analgesic
efficacy of paracetamol-codeine combinations versus paracetamol
alone: A systematic review. BMJ 1996;313:321-325. (Review)
26. Turturro MA, Paris PM, Yealy DY, et al. Hydrocodone versus codeine
in acute musculoskeletal pain. Ann Emerg Med 1991;20-1100-1104.
(Double-blind, prospective; 50 patients)
27. Li Wan Po A, Zhang WY. Systematic overview of co-proxamol to
assess analgesic effects of addition of dextropropoxyphene to
paracetamol. BMJ 1997;315:1565-1571. (Review)
Although formal hypnosis is rarely practiced in the
ED, we must never underestimate the power of suggestion. Higher brain functions can actively modulate the
response to painful stimuli. If patients believe a medication will control their pain, they are more likely to
respond to the drug. A physician who suggests, “Maybe
this will help—maybe not” is less likely to relieve
suffering than one who affirms, “We will make you feel
better.” A reassuring manner, distracting attention from
the painful stimulus, and the use of adjuncts such as
music, television, and videos in the ED will ease pain’s
dolorous sting.
Summary
Most patients come to EDs because of pain. Sadly, many
physicians fall short when it comes to pain management.
Numerous misconceptions and bad habits cripple their
practice. Common failings include not making pain
management a priority, the routine use of intramuscular
agents to treat pain, frequent use of less effective agents
such as codeine or propoxyphene, and under-dosing of
opioid analgesics.
When a patient arrives in the ED acutely short of
breath, no physician waits for a final diagnosis before
giving oxygen. Similarly, when a patient presents to the
ED in pain, treat it quickly, and aggressively. In most
situations, treatment of pain should occur in parallel to
patient evaluation.. In the case of abdominal pain, studies
show that pain relief does not obscure the diagnosis. If
necessary, remind the consultant that CT scans are not
influenced by administration of morphine.
Routinely incorporate pain measurement into
patient evaluation. Be proactive—don’t wait for the
patient to ask for pain medication, but offer analgesics
early during care. It’s useful to remember that our
calling remains “To cure sometimes, to relieve often,
and to comfort always.”54 ▲
References
Evidence-based medicine requires a critical appraisal of the
literature based upon study methodology and number of
subjects. Not all references are equally robust. The findings
of a large, prospective, randomized, and blinded trial
should carry more weight than a case report.
To help the reader judge the strength of each
reference, pertinent information about the study, such as
the type of study and the number of patients in the study,
will be included in bold type following the reference,
where available. In addition, the most informative
Emergency Medicine Practice
14
December 1999
28.
29.
30.
31.
*32.
33.
*34.
35.
36.
37.
38.
39.
*40.
41.
42.
43.
44.
45.
46.
47.
48.
*49.
50.
51.
52.
*53.
54.
55.
56.
Physician CME Questions
Web site of the Metropolitan Nashville Police Department (http://
www.nashville.net/~police/citizen/vice.htm.)
Moore PA, Crout RJ, Jackson DL, et al. Tramadol hydrochloride:
Analgesic efficacy compared with codeine, aspirin with codeine, and
placebo after dental extraction. J Clin Pharm 1998;38:554-560.
(Randomized, double-blind clinical trial; 200 patients)
Turturro MA, Paris PM, Larkin GL. Tramadol versus hydrocodone
with acetaminophen in acute musculoskeletal pain: A randomized,
controlled clinical trial. Ann Emerg Med 1998;32:139-143. (Randomized,
double-blind clinical trial; 68 patients)
Brooks PM, Day RO. Nonsteroidal anti-inflammatory drugs—
differences and similarities. N Engl J Med 1991;324:1716-1725. (Review)
Griffin MR, Piper JM, Daugherty JR, et al. Nonsteroidal antiinflammatory drug use and increased risk for peptic ulcer disease in
elderly persons. Ann Intern Med 1991;114:257-263. (Case-controlled
study; 8478 patients)
Catapano MS. The analgesic efficacy of ketorolac for acute pain.
J Emerg Med 1996;14:67-75. (Review)
Turturro MA. Intramuscular ketorolac versus oral ibuprofen in acute
musculoskeletal pain. Ann Emerg Med 1995;26:117-120. (Prospective;
82 patients)
Shrestha M. Randomized double-blind comparison of the analgesic
efficacy of intramuscular ketorolac and oral indomethacin in the
treatment of acute gouty arthritis. Ann Emerg Med 1995;26:682-686.
(Comparative study; 20 patients)
Wright JM. NSAID use and efficacy in the emergency department:
Single doses of oral ibuprofen versus intramuscular ketorolac. Ann
Pharmacother 1994;28:309-312. (Comparative study)
Tramer MR, Williams JE, Carroll D, et al. Comparing analgesic efficacy
of nonsteroidal anti-inflammatory drugs given by different routes in
acute and chronic pain: A qualitative systematic review. Acta Anaesth
Scand 1998;42:71-79. (Review)
Schwartz N, Istvan D, Turturro MA, et al. Perceived mode of
NSAID administration and its effect on analgesia. Acad Emerg Med
(in press).
Celecoxib for arthritis. Med Lett Drugs Ther 1999;41:11-12. (Review)
Morrison BW, Christensen S, Yuan W, et al. Analgesic efficacy of the
cyclooxygenase-2-specific inhibitor rofecoxib in post-dental surgery
pain: A randomized, controlled trial. Clin Ther 1999;21:943-953.
(Randomized, controlled trial; 151 patients)
Mohammed S, Croom DW 2d. Gastropathy due to celecoxib, a
cyclooxygenase-2 inhibitor. N Engl J Med 1999;340:2005-2006. (Letter)
DeLee JC, Rockwood CA. Skeletal muscle spasm and a review of
muscle relaxants. Curr Ther Res 1980;27:64-74. (Review)
Borenstein DG, Lacks S, Wiesel SW. Cyclobenzaprine and naproxen
versus naproxen alone in the treatment of acute low back pain
and muscle spasm. Clin Ther 1990;12:125-131. (Comparative study;
40 patients)
DiPallma JR, DiGregorio GJ. Management of low back pain
by analgesics and adjuvant drugs. Mt Sinai J Med 1991;58:
101-108. (Review)
Ronchi L, et al. Femoral nerve blockade in children using bupivacaine.
Anesthesiology 1989;70:622-624.
McGlone R, Sadhra K, Hamer DW, et al. Femoral nerve block in the
initial management of femoral shaft fractures. Arch Emerg Med
1987;4(3):163-168.
Colaric KB, Overton DT, Moore K. Pain reduction in lidocaine
administration through buffering and warming. Am J Emerg Med
1998;16:353-356. (Comparative study; 20 volunteers)
Bartfield JM, Crisafulli KM, Raccio-Robak N, et al. The effects of
warming and buffering on pain of infiltration of lidocaine. Acad Emerg
Med 1995;2:254-258.
Scarfone RJ, Jasani M, Gracely EJ. Pain of local anesthetics: Rate of
administration and buffering. Ann Emerg Med 1998;31:36-40.
(Comparative study; 42 adult volunteers)
Bartfield JM, Holmes TJ, Raccio-Robak N. A comparison of
proparacaine and tetracaine eye anesthetics. Acad Emerg Med
1994;1:364-367.
Daya MR, Burton BT, Schleiss MR, et al. Recurrent seizures following
mucosal application of TAC. Ann Emerg Med 1988;17(6):646-648.
Dailey RH. Fatality secondary to misuse of TAC solution. Ann Emerg
Med 1988;17(2):159-160.
Ernst A, Marvez-Valls E, Nick TG. LAT (lidocaine-adrenalinetetracaine) versus TAC (tetracaine-adrenaline-cocaine) for
topical anesthesia in face and scalp lacerations. Am J Emerg Med
1995;13:151-154.
Strauss MB, ed. Familiar Medical Quotations. Boston: Little, Brown and
Company; 1968.
Henry G, personal communication.
The Columbia Dictionary of Quotations is licensed from Columbia
University Press. Copyright © 1993, 1995 by Columbia University
Press. All rights reserved.
December 1999
57. All of the following have been identified as risk
factors for oligoanalgesia except:
a. age.
b. gender.
c. ethnicity.
d. abdominal pain.
58. The most appropriate initial dose of morphine
sulfate in an 80 kg 28-year-old male with an
isolated upper extremity fracture is:
a. 2 mg IV.
b. 4 mg IV.
c. 8 mg IV.
d. 15 mg IV.
59. All of the following are opioid agonist/antagonist
analgesics except:
a. pentazocine.
b. butorphanol.
c. dezocine.
d. tramadol.
60. Which of the following is a schedule II
opioid analgesic?
a. Hydromorphone.
b. Hydrocodone.
c. Pentazocine.
d. Codeine.
61. Which of the following is not true regarding
ketorolac 60 mg IM?
a. It’s the only injectable NSAID available in the U.S.
b. It’s as effective as escalating titrated doses
of morphine.
c. The pharmacy cost is approximately $7.
d. It may cause gastrointestinal distress.
62. Which agent has weak opioid receptor agonist
properties and inhibits monoamine reuptake?
a. Meperidine
b. Tramadol
c. Ketorolac
d. Amitriptyline
63. Which is not true regarding meperidine?
a. Its metabolite may be a CNS irritant.
b. It can have a dangerous interaction with
MAO inhibitors.
c. It is frequently underdosed in the ED.
d. It has a longer duration of action than morphine.
64. Which local anesthetic is absorbed and effective in
intact skin?
a. Bupivacaine
b. TAC
c. Benzocaine
d. EMLA
15
Emergency Medicine Practice
Physician CME Information
65. Which is not a property of morphine?
a. Histamine release
b. Lowering of seizure threshold
c. Sedation
d. Inexpensive compared to other narcotic agents
This CME enduring material is sponsored by Carolinas HealthCare System
and has been planned and implemented in accordance with the Essentials
and Standards of the Accreditation Council for Continuing Medical
Education. Credit may be obtained by reading each issue and completing
the post-tests administered in December and June.
66. Which agent has a synergistic analgesic effect if
given with an opioid?
a. Acetaminophen
b. Promethazine
c. Hydroxyzine
d. Midazolam
Target A udienc e: This enduring material is designed for emergency
medicine physicians.
Needs A ssessmen t: The need for this educational activity was determined
by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS,
and ACEP; and evaluation of prior activities for emergency physicians.
Date of O riginal R elease: This issue of Emergency Medicine Practice
was published December 1, 1999. This activity is eligible for CME credit
through December 1, 2000. The latest review of this material was
November 24, 1999.
Discussion of I nvestiga tional I nformation: As part of the newsletter,
faculty may be presenting investigational information about
pharmaceutical products that is outside Food and Drug Administration
approved labeling. Information presented as part of this activity is
intended solely as continuing medical education and is not intended
to promote off-label use of any pharmaceutical product. Disclosure of
Off-Label Usage: This issue of Emergency Medicine Practice discusses no offlabel use of any phamaceutical product.
Facult y Disclosur e: In compliance with all ACCME Essentials, Standards,
and Guidelines, all faculty for this CME activity were asked to complete a
full disclosure statement. The information received is as follows: Dr.
Turturro and Dr. Ducharme report no significant financial interest or other
relationship with the manufacturer(s) of any commercial product(s)
discussed in this educational presentation.
Accreditation: Carolinas HealthCare System is accredited by the
Accreditation Council for Continuing Medical Education to sponsor
continuing medical education for physicians.
Credit D esigna tion: Carolinas HealthCare System designates this
educational activity for up to 2 hours of Category 1 credit toward the
AMA Physician’s Recognition Award. Each physician should claim only
those hours of credit actually spent in the educational activity. Emergency
Medicine Practice is approved by the American College of Emergency Physicians for 24 hours of ACEP Category 1 credit (per annual subscription).
Earning C redit: Physicians with current and valid licenses in the United
States, who read all CME articles during each Emergency Medicine Practice
six-month testing period, complete the CME Evaluation Form distributed
with the December and June issues, and return it according to the
published instructions are eligible for up to 2 hours of Category 1 credit
toward the AMA Physician’s Recognition Award (PRA) for each issue. You
must complete both the post-test and CME Evaluation Form to receive
credit. Results will be kept confidential. CME certificates will be mailed to
each participant scoring higher than 70% at the end of the calendar year.
This test concludes the first semester testing period of
Emergency Medicine Practice. The answer form for this
semester and a postage-paid return envelope have been
included with this issue. All paid subscribers are eligible to
take this test. You will need the customer number printed on
the outer envelope to submit the post-test. Please refer to the
instructions printed on the answer form.
Class Of Evidence Definitions
Each action in the clinical pathways section of Emergency
Medicine Practice receives an alpha-numerical score based on
the following definitions.
Class I
• Always acceptable, safe
• Definitely useful
• Proven in both efficacy
and effectiveness
• Must be used in the
intended manner for
proper clinical indications
Level of Evidence:
• One or more large
prospective studies
are present (with
rare exceptions)
• Study results consistently
positive and compelling
Class IIa
• Safe, acceptable
• Clinically useful
• Considered treatments
of choice
Level of Evidence:
• Generally higher levels
of evidence
• Results are consistently
positive
Class IIb
• Safe, acceptable
• Clinically useful
• Considered optional or
alternative treatments
Level of Evidence:
• Generally lower or
intermediate levels
of evidence
• Generally, but not
consistently, positive results
Emergency Medicine Practice
Class III:
• Unacceptable
• Not useful clinically
• May be harmful
Level of Evidence:
• No positive high-level data
• Some studies suggest or
confirm harm
Indeterminate
• Continuing area of research
• No recommendations until
further research
Level of Evidence:
• Evidence not available
• Higher studies in progress
• Results inconsistent,
contradictory
• Results not compelling
Publisher : Robert Williford. Vice Presiden t/General Manager : Connie Austin.
Executiv e Editor: Heidi Frost.
Direct all editorial or subscription-related questions to Pinnacle
Publishing, Inc.: 1-800-788-1900 or 770-565-1763
Fax: 770-565-8232
Pinnacle Publishing, Inc.
P.O. Box 72255
Marietta, GA 30007-2255
E-mail: emer gmed@pinpub .com
Adapted from: The Emergency
Cardiovascular Care Committees
of the American Heart Association
and representatives from the
resuscitation councils of ILCOR:
How to Develop Evidence-Based
Guidelines for Emergency Cardiac
Care: Quality of Evidence and
Classes of Recommendations; also:
Anonymous. Guidelines for
cardiopulmonary resuscitation and
emergency cardiac care. Emergency Cardiac Care Committee and
Subcommittees, American Heart
Association. Part IX. Ensuring
effectiveness of community-wide
emergency cardiac care. JAMA
1992;268(16):2289-2295.
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Emergency Medicine Practice (ISSN 1524-1971) is published monthly (12 times per year)
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covers a highly technical and complex subject and should not be used for making
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December 1999