A Review of Current and Emerging Approaches to Pain Management in the Emergency Department

Abstract

Introduction: Pain is the most common symptom prompting an emergency department visit and emergency physicians are responsible for managing both acute pain and acute exacerbations of chronic pain resulting from a broad range of illnesses and injuries. The responsibility to treat must be balanced by the duty to limit harm resulting from analgesics. In recent years, opioid-related adverse effects, including overdose and deaths, have increased dramatically in the USA. In response to the US opioid crisis, emergency physicians have broadened their analgesic armamentarium to include a variety of non-opioid approaches. For some of these therapies, sparse evidence exists to support their efficacy for emergency department use. The purpose of this paper is to review historical trends and emerging approaches to emergency department analgesia, with a particular focus on the USA and Canada.

Methods: We conducted a qualitative review of past and current descriptive studies of emergency department pain practice, as well as clinical trials of emerging pain treatment modalities. The review considers the increasing use of non-opioid and multimodal analgesic therapies, including migraine therapies, regional anesthesia, subdissociative-dose ketamine, nitrous oxide, intravenous lidocaine and gabapentinoids, as well as broad programmatic initiatives promoting the use of non-opioid analgesics and nonpharmacologic interventions.

Results: While migraine therapies, regional anesthesia, nitrous oxide and subdissociative-dose ketamine are supported by a relatively robust evidence base, data supporting the emergency department use of intravenous lidocaine, gabapentinoids and various non-pharmacologic analgesic interventions remain sparse.

Conclusion: Additional research on the relative safety and efficacy of non-opioid approaches to emergency department analgesia is needed. Despite a limited research base, it is likely that non-opioid analgesic modalities will be employed with increasing frequency. A new generation of emergency physicians is seeking additional training in pain medicine and increasing dialogue between emergency medicine and pain medicine researchers, educators and clinicians could contribute to better management of emergency department pain.

Keywords: Acute pain; Emergency medicine; Gabapentinoids; Ketamine; Lidocaine; Nitrous oxide; Non-opioid analgesics pain; Pain medicine; Regional anesthesia.

Fig. 1

Patient perceived need for, and administration of, analgesics. Reprinted from Todd et al. [17], with permission from Elsevier

Fig. 2

Patient satisfaction. Reprinted from Todd et al. [17], with permission from Elsevier

Fig. 3

Mean pain scores with standard errors for pain at ED admission (baseline) and 1 and 2 h after admission for control (solid lines) and intervention (dashed lines). Reproduced with permission from Morrison et al. [37]

Fig. 4

Mean pain scores for pain at rest, with transfer out of bed, and with walking for control (shaded) and intervention (hashed) subjects on postoperative day 3. Reproduced with permission from Morrison et al. [37]