Essential pharmacologic options for acute pain management in the emergency setting

Abstract

Pain is the root cause for the overwhelming majority of emergency department (ED) visits worldwide. However, pain is often undertreated due to inappropriate analgesic dosing and ineffective utilization of available analgesics. It is essential for emergency providers to understand the analgesic armamentarium at their disposal and how it can be used safely and effectively to treat pain of every proportion within the emergency setting. A 'balanced analgesia' regimen may be used to treat pain while reducing the overall pharmacologic side effect profile of the combined analgesics. Channels-Enzymes-Receptors Targeted Analgesia (CERTA) is a multimodal analgesic strategy incorporating balanced analgesia by shifting from a system-based to a mechanistic-based approach to pain management that targets the physiologic pathways involved in pain signaling transmission. Targeting individual pain pathways allows for a variety of reduced-dose pharmacologic options - both opioid and non-opioid - to be used in a stepwise progression of analgesic strength as pain advances up the severity scale. By developing a familiarity with the various analgesic options at their disposal, emergency providers may formulate safe, effective, balanced analgesic combinations unique to each emergency pain presentation.

Keywords: Balanced analgesia; CERTA; Emergency medicine; Non-opioids; Opioids; Pain management.

Fig. 1

Analgesic Pyramid. The analgesic pyramid emphasizes a stepwise approach to analgesics - opioid and non-opioid - with progression in analgesic strength as pain progresses up the severity scale.

Fig. 2

Comparison of common opioid analgesic potency. Hydromorphone is approximately 7-fold more potent than morphine; fentanyl is approximately 100-fold more potent than morphine.