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

Abstract

IntroductionPain 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.MethodsWe 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.ResultsWhile 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.ConclusionAdditional 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.

Procedural pain management in a community emergency department: A pilot study of feasibility and efficacy

“…One US Emergency Department in particular has been extremely successful in promoting nonopioid management, with a focus on procedural pain management -such as nerve blocks and trigger point injections [9]. Along this line, there is increasing interest among Emergency Physicians to obtain new training and skills to improve pain management in the ED [10].…”

Multimodal Transport Network Optimization Considering Safety Stock under Real-Time Information

“…With the update of demand information, enterprises can effectively deal with the mismatch between supply and demand through the multimodal transport logistics supply network, which can reduce inventory backlog and improve customer service level [4][5][6][7][8]. The imbalance of inventory control caused by mismatch between supply and demand can be handled by means of emergency ordering or by multimodal transport from the transshipment center [9][10][11][12][13][14][15]. The problem of emergency ordering is that the adjustment of production resources and the compression of the construction period will inevitably lead to high costs [16][17][18][19][20].…”

“…Therefore, more and more enterprises tend to adopt multimodal transport to deal with the problem of supply and demand mismatch between regions [21]. Previous studies showed the significance of multimodal transport problems [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] and solutions [21] that can be improved from different perspectives. For instance, Mengliang et al [1], Todd et al [2], and Pałaszewskatkacz et al [3] showed that demand information cannot be ignored; references [4][5][6][7][8] found the importance of requirements updates; researchers [9][10][11][12][13][14][15] emphasized that safety stock should be considered in multimodal transport; costs control should be considered in multimodal transportation optimization from literatures [16][17][18][19][20]; and Zhang et al [21] provided a good method reference for multimodal transport network optimization problem.…”

Intramuscular versus oral diclofenac for acute pain in adults with acute musculoskeletal injuries presenting to the ED setting: a prospective, double-blind, double-dummy, randomised controlled trial

“…Pain alleviation is a well-established clinical priority in emergency medicine (EM). 1 Recent years have seen ED practice shift towards increased use of non-opioids such as non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol, which do not have opioids' dependency-related risks. [1][2][3] Diclofenac is an NSAID commonly used in the ED for conditions such as musculoskeletal injury (MSI) and renal colic.…”

“…1 Recent years have seen ED practice shift towards increased use of non-opioids such as non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol, which do not have opioids' dependency-related risks. [1][2][3] Diclofenac is an NSAID commonly used in the ED for conditions such as musculoskeletal injury (MSI) and renal colic. 4 5 Administered in adult doses ranging from 50 to 100 mg, diclofenac mediates analgesia primarily via inhibition of cyclo-oxygenase-2 (COX-2) enzymatic conversion of arachidonic acid into inflammatory prostaglandins.…”