Comparing Nonopioids Versus Opioids for Acute Pain in the Emergency Department: A Literature Review

Abstract

Background: Pain is the most common reason for patient visits in the emergency department (ED). Opioids have been long considered the standard of care for acute pain in the ED. Because of the opioid crisis, investigation and implementation of novel practices to manage pain is needed. The use of various nonopioids has been suggested as a plausible alternative to opioids, with emerging literature to support its use for acute pain in the ED. Study Question: To evaluate the safety, efficacy, opioid-sparing effects of nonopioids in patients who present with acute pain in the ED. Data Sources: We systematically searched PubMed and EMBASE (July 1970 to January 2019). Study Design: Randomized controlled trials that evaluated nonopioids versus opioids in the ED were eligible. The clinical outcomes measured were change in pain scores compared with baseline, the incidence of adverse events, and use of rescue analgesia. Results: Twenty-five randomized controlled trials that evaluated the use of nonopioids in 2323 patients [acetaminophen (APAP) (n = 651), diclofenac (n = 547), ketamine (n = 272), ketorolac (n = 225), lidocaine (n = 219), ibuprofen (n = 162), ibuprofen & APAP (n = 162), hydroxyzine & dihydroergotamine (n = 85)] met inclusion criteria. Four trials found significant greater reductions in pain scores, favoring nonopioids. In all trials, the duration of pain relief provided by nonopioids was not sustained over an extended period. Eighteen trials reported no significant differences in reduction of pain scores. Two trials reported improved pain reduction with opioids and one trial reported noninferiority. Conclusions: Evidence from primary literature suggests that nonopioids could be a feasible alternative to opioids for management of acute pain in the ED as it is effective, safe, and decreases the need for rescue analgesia.

Guidelines for Reasonable and Appropriate Care in the Emergency Department 2 (GRACE‐2): Low‐risk, recurrent abdominal pain in the emergency department

“…We considered the possibility of abdominal pain as a manifestation of depression and depression as a consequence of unremitting abdominal pain. The ongoing opioid epidemic in the United States, as well as clinical experience and studies noting frequent opioid prescribing in the ED setting of recurrent abdominal pain, prompted consideration of opioid use disorder screening and alternative methods of pain control 3,17–26,28–30,78–86 …”

“…The ongoing opioid epidemic in the United States, as well as clinical experience and studies noting frequent opioid prescribing in the ED setting of recurrent abdominal pain, prompted consideration of opioid use disorder screening and alternative methods of pain co ntrol. 3,[17][18][19][20][21][22][23][24][25][26][28][29][30][78][79][80][81][82][83][84][85][86] An important consideration for the GRACE-2 writing group was the feasibility of the guideline for physicians and patients in various practice settings. We debated including recommendations for testing for conditions such as Helicobacter pylori but noted that some forms of testing such as exhaled carbon dioxide or immunological testing might not be available within an ED time frame in some settings.…”

Efficacy of prescribed opioids for acute pain after being discharged from the emergency department: A systematic review and meta‐analysis

“…Others have found that opioids are not superior to NSAIDs or acetaminophen at reducing acute pain in a prehospital setting 25 . However, another literature review on musculoskeletal pain in the ED reported that “No interventions were more effective at decreasing pain intensity than opioids at 60 min.” 26 Furthermore, a prospective cohort study of ED patients discharged with an opioid prescription showed that patients using opioids were more likely to report pain relief than those using NSAIDs and/or acetaminophen 27 . Nonetheless, the study was observational, not controlled or randomized.…”