A Review of Current and Emerging Approaches to Pain Management in the Emergency Department
A Review of Current and Emerging Approaches to Pain Management in the Emergency Department
Knox H. Todd 0
0 K. H. Todd (&) EMLine.org , Mendoza , Argentina
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
Acute pain; Emergency medicine; Gabapentinoids; Ketamine; Lidocaine; Nitrous
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
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
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.
oxide; Non-opioid analgesics
medicine; Regional anesthesia
Pain is the most common reason for seeking
emergency department (ED) care and, as a
presenting complaint, pain accounts for up to
seventy percent of ED visits . Descriptive
studies of ED pain practice began appearing in
the 1990s and many of these investigators
discovered that specific patient subgroups were at
risk for inadequate pain treatment. Those at risk
included the very young, older adults and
members of minority ethnic groups [
number of efforts to increase awareness of
unmet pain treatment needs, both in the ED
and other settings, originated in the USA and
Canada in the mid-1990s [
campaigns to promote pain treatment became
widespread throughout the healthcare system
and, in particular, an increased emphasis on
standardized pain assessment was promulgated
by the Joint Commission on the Accreditation
of Healthcare Organizations, soon to be
renamed The Joint Commission [
As a consequence of these efforts, and in part
due to industry marketing, pharmacologic
approaches to pain treatment (particularly the
use of opioids) became more aggressive. The
opioid-centric nature of this change in practice
soon became apparent, as the number of
opioids prescribed by all healthcare providers
increased dramatically over the following
decade. US opioid prescribing peaked in 2010 at
782 morphine milligram equivalents (MME) per
capita. As of 2015, this volume had decreased to
640 MME per capita, but remained three times
higher than levels in 1999 [
Importantly, the USA ranks number one in
the consumption of prescription opioids
globally, with a per capita consumption rate two to
three times that of European countries [
Recent studies of prescription opioid misuse
and abuse in Canada and Australia suggest
increasing levels of harm while countries of the
European Union report disparate rates of
prescription opioid abuse [
]. The reasons for
these cross-national consumption disparities are
no doubt complex, related to multiple cultural
and pharmaceutical marketing differences, and
beyond the scope of this review.
In this paper, we present a qualitative review
of past and current descriptive studies of ED
pain practice, as well as clinical trials of
emerging pain treatment modalities. Our
purpose is to review historical trends and emerging
approaches to ED analgesia, with a particular
focus on the USA and Canada. This article is
based on previously conducted studies and does
not involve any new studies of human or
animal subjects performed by any of the authors.
CURRENT STANDARD TREATMENTS
A prospective, multicenter study published in
2007 provides a snapshot of US and Canadian
ED practice at perhaps the height of an
opioid-centric analgesic approach to pain
]. Investigators enrolled 842 patients
age 8 years or older presenting to the ED with
moderate to severe pain ([3 on an 11-point
numerical rating scale) to one of 20 EDs.
Contrary to common belief that most ED pain
results from injury or trauma, only 32%
presented with pain of traumatic etiology (Table 1).
Common nontraumatic diagnostic groups
included neck and back pain, abdominal pain,
headache, noncardiac chest pain and upper
Pain intensity ratings on arrival ranged from
4 to 10 with a median pain score of 8. Only 50%
of patients had a 2-point or greater reduction in
numeric rating scale (NRS) pain intensity scores
during the ED stay. Almost three quarters of
patients were discharged in moderate pain
(45%; NRS, 4–7) or severe pain (29%; NRS,
Overall, 589 of 842 subjects (70%) expressed
a desire for analgesics, and 506 of these (86%)
received them. The median time interval from
triage to analgesic administration was 90 min,
and fewer than one third of patients received
analgesics within 1 hour of arrival (Fig. 1). A
total of 735 doses of 24 different analgesics were
administered in the ED. The majority of
analgesics administered were opioids (59%):
Wound, abrasion or contusion
Sprain or strain
Back or neck pain
Fracture or dislocation
Chest pain (noncardiac)
Upper respiratory infection
Abscess or cellulitis
Urinary tract infection
Total with ICD-9 diagnosis
morphine was the single most commonly
administered analgesic (20%), followed by
ibuprofen (17%; Table 2). Despite rather small
reductions in pain intensity, patients expressed
relatively high satisfaction with both overall
pain treatment and staff responses to reports of
Fig. 2 Patient satisfaction. Reprinted from Todd et al.
], with permission from Elsevier
pain (median scores of 5 on a 6-point scale;
Over the first decade of the current century,
evidence of prescription opioid-related harm,
including overdose and death, became painfully
obvious in the USA. Since 1999, overdose deaths
involving prescription opioids, as well as total
sales of prescription opioids, have quadrupled
While it is difficult to estimate the precise
contribution of ED opioid prescribing to the rise
in prescription opioid harm in the USA, recent
studies suggest that the contribution of
emergency medicine is limited. In 2012, emergency
medicine as a specialty accounted for only four
percent of US opioid prescriptions, ranking
behind dentists, surgeons, internists and family
]. The number of doses per
prescription suggests an even smaller role for the
specialty. In a study of 19 US EDs, 17% of
patients received opioid prescriptions at
discharge with an average of only 15 pills per
Nonetheless, over the last decade, initiatives
to increase scrutiny of those seeking pain
treatment in the ED, including widespread use
of prescription drug monitoring programs, have
become widespread [
]. Professional societies,
regulatory bodies and individual EDs have
created guidelines to limit and standardize opioid
]. As a result of these efforts,
emergency physician opioid-prescribing rates
dropped by almost ten percent between 2007
and 2012 . With increasing frequency,
emergency physicians are incorporating
non-opioid alternatives and multimodal
analgesic options into practice [
In the remainder of this review, we consider the
increasing use of non-opioid and multimodal
analgesic therapies, as well as the need for
additional research and quality improvement
activities to promote safe and effective ED pain
For treatment of some common ED pain
presentations, such as benign headache, robust
evidence exists to support non-opioid and
migraine-specific modalities. Despite
well-accepted evidence, progress toward standardizing
US and Canadian ED headache treatment and
giving primacy to non-opioid interventions of
known efficacy (i.e., dopamine agonists,
serotonin agonists) has been remarkably slow
]. Almost 20 years after the Canadian
Association of Emergency Physicians published
guidelines for the acute management of
migraine headaches [
], evidence reviews
reveal that opioids remain the first line of
treatment for large proportions of US and
Canadian ED patients with benign headaches
]. While opioid administration is less
common in non-North American EDs [
migraine-specific therapies are likely
underutilized in ED settings worldwide. The crisis of
prescription opioid harm in the USA provides
additional stimulus to harmonize rational
migraine therapy across national boundaries.
Emergency physician-administered regional
anesthesia is another modality that is well
supported by the literature and appears ripe for
expansion. Fostered by the ubiquity of
emergency medicine training programs in
ultrasound, local and regional nerve blockade are
increasingly employed for a large variety of
painful injuries and illnesses [
A recent multicenter randomized controlled
trial of regional nerve blockade for elderly patients
with hip fractures illustrates the evolving role of
emergency physicians in the delivery of regional
anesthesia and the teamwork between emergency
medicine and anesthesiology required to achieve
optimal pain control and functional outcome for
these often frail patients [
]. In this study, 161 ED
patients with acute hip fractures from three New
York City hospitals were randomized to receive
either an ultrasound-guided, single-injection
femoral nerve block administered by emergency
physicians followed by placement of a continuous
fascia iliaca block by anesthesiologists within
24 h, or opioid analgesics alone. Although both
arms allowed opioids as needed, pain scores in the
ED favored the intervention group over controls,
as did pain scores on post-operative day 3 (Figs. 3,
4). Intervention subjects required one third fewer
morphine milligram equivalents and reported
fewer opioid adverse effects. Perhaps more
surprisingly, intervention subjects reported superior
functional status, including walking and stair
climbing ability, up to 6 weeks after their initial
Intravenous subdissociative-dose ketamine
has also been the subject of a number of recent
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. 
ED studies. Perhaps because ketamine has long
been used for procedural sedation and as an
induction agent for rapid sequence intubation,
subdissociative-dose ketamine (0.1–0.4 mg/kg)
as monotherapy or adjunctive therapy has
become more rapidly adopted for use than
other non-opioid analgesics.
In a recent position paper from the American
Academy of Emergency Medicine,
subdissociative-dose ketamine was judged safe and effective
both as a single agent and in combination with
opioids for the treatment of acute pain [
Although ketamine is well known to cause
troubling neuropsychiatric adverse effects
(emergence phenomena), in subdissociative
doses these adverse effects appear to be minor
and short-lived. Eight supportive studies of
subdissociative-dose ketamine pertinent to
pre-hospital and ED settings have been
published over the last 10 years [
recent study examined adverse effects and
analgesic efficacy of ketamine administered as
either a single intravenous push (IVP) or a short
infusion over 15 min . Using a
double-dummy design, the investigators reported
similar analgesic efficacy with fewer reports of
adverse effects for when ketamine was infused
over a 15-min infusion period.
While subdissociative-dose ketamine, as
either monotherapy or multimodal therapy, is
generally supported by published evidence to
date, emergency physicians should inform
patients about potential side effects and avoid
ketamine for patients with underlying
psychiatric disorders or substance abuse-induced
transient psychosis. Ketamine should be
administered in accordance with established
departmental policies and procedures.
Nitrous oxide has a long history of use as
both an anxiolytic and analgesic among
pediatric ED patients. Administered as a 50%–70%
nitrous oxide vapor, it is used for children
undergoing a number of procedures, including
venipuncture, laceration repair, fracture
reduction as well as incision and drainage of
abscesses. Its use has been limited by the need for
proper ventilation and scavenging equipment
as well as the documented potential for staff
recreational use [
]. Nitrous oxide has seen less
use among adult ED patients. In a recent
non-controlled pilot study of self-administered
nitrous oxide among 85 ED patients with
abscesses or orthopedic injuries, nitrous oxide
appeared to be safe and well tolerated. Given
the current emphasis on decreasing opioid use
in the ED, it is likely that nitrous oxide use will
increase over time [
In contrast to the modalities discussed
above, a number of non-opioid analgesics for
which there is less robust evidence are receiving
increased attention. Analgesic therapies such as
intravenous lidocaine, gabapentinoids, trigger
point injections and even acupuncture,
mind–body approaches and music therapy have
recently been promoted for ED use [
Intravenous lidocaine has demonstrated
efficacy for central pain syndromes and
neuropathic pain, as well as opioid-sparing effects in
the post-operative setting. Two Iranian research
groups recently published studies of
intravenous lidocaine for ED the treatment of renal
colic. The first studied intravenous lidocaine as
an adjuvant to opioid therapy in 110 patients
presenting to the ED with typical renal colic
]. The investigators reported that
those treated with a combination of lidocaine
and morphine reported fewer episodes of
nausea and more rapid resolution of both pain and
nausea than those treated with morphine alone.
A second study of 240 patients with renal colic
directly compared monotherapy with
intravenous lidocaine to morphine [
reduction was reported to be greater over the
first 30 min for those treated with lidocaine. In
another US study comparing intravenous
lidocaine to intravenous ketorolac for ED patients
with acute radicular back pain, lidocaine was
less impressive, failing to reach a clinically
significant reduction in reported pain intensity
over 60 min [
While intravenous lidocaine has thus far
received limited investigation in the ED, other
non-opioid and nonpharmacologic approaches,
such as the use of gabapentinoids, trigger point
injections and even acupuncture, mind–body
therapies and music therapy, have received
little rigorous study. Perhaps the most ambitious
ED program encouraging non-opioid analgesic
therapies as well as a variety of
nonpharmacologic therapies is the Alternatives to Opiates
Program (ALTO) developed by St. Joseph’s
Regional Medical Center in Patterson, New
Jersey, USA [
]. Initiated formally in January
2016, ALTO encourages multimodal treatments
for five specific conditions: acute low back pain,
lumbar radiculopathy, renal colic, migraine and
Condition-specific multimodal therapeutic protocols
include a variety of non-opioid analgesics,
specifically non-steroidal anti-inflammatory
agents, ketamine, lidocaine/ropivacaine,
benzodiazepines, corticosteroids, gabapentinoids
and nitrous oxide. Ultrasound-guided regional
anesthesia is advised for appropriate extremity
fractures and dislocations. Although opioids are
allowed as rescue analgesics in these protocols,
alternatives to opioids are administered when
possible. The program encourages discussions
with patients of opioid adverse effects and
addiction risks, and program goals include the
incorporation of medically assisted treatment of
opioid addiction, acupuncture and mind–body
modalities. Although published data is limited,
the program claims to have reduced opioid
administration for selected conditions by
While this review concentrates on ED
analgesics, the sole focus on pharmacologic
intervention risks overlooking nonpharmacologic
measures that can be employed effectively in
the ED. Given the adverse effects associated
with many opioid (and non-opioid) analgesics,
it is important to understand and employ such
treatments, including patient-centered
communication techniques, physical interventions
and relaxation techniques.
Additionally, for complaints such as pain, the
emergency physician often lacks obvious
confirmatory evidence of an inciting factor (e.g.,
migraine, low back pain). Those in pain often
present with co-morbid anxiety and depression,
or exhibit low self-efficacy, catastrophizing
ideation or behaviors typical of chemical
coping. Such patients may be perceived as ‘‘difficult’’
and challenge our professional competence and
ability to maintain a positive therapeutic stance
]. Negative stereotypes or stigmatization of
those in pain impair the patient-physician
relationship and predictably result in inadequate
clinical care [
Particularly in the context of an ongoing
national crisis of opioid harm, it is important
that emergency physicians display empathy in
treating patients who may (or may not) be at
risk for opioid abuse. The concept of empathy
for those in pain involves cognitive (the ability
to envision standing in another’s shoes),
affective (the appreciation of another’s emotional
state) and action (patient-centered
communication) elements. The ability to display
empathy and provide patient-centered
communication are core competencies for
emergency physicians [
interactions characterized by empathy and trust
are more likely to lead to optimal outcomes
]. Although we lack sufficient ED research
into the phenomenon, such ‘‘empathetic
attention’’ has the potential reduce analgesic
needs, particularly for patients with high levels
of anxiety, and should be considered an integral
tool in our therapeutic armamentarium [
Clinicians who successfully integrate these
skills into practice will likely realize higher
levels of patient satisfaction, enhanced
treatment compliance and better clinical outcomes.
To the extent that these practices promote
patient self-efficacy and self-management of
pain, healthcare costs related to unnecessary
diagnostic imaging and adverse effects of
inappropriate prescribing may also be reduced [
Finally, enhancing emergency physician
empathy for those in pain has the potential to reduce
career burnout [
], increase physician
well-being  and lower medicolegal risk [
A number of recent developments are
encouraging to those promoting excellence in ED pain
management. After many years of discussion,
emergency medicine residency training has
become an accepted pathway into US pain
medicine fellowships and a small but growing
number of emergency physicians are now
dual-certified in both specialties. Emergency
physicians seeking dual certification will be
more likely to pursue academic careers and
promote a higher level of scholarship in
pain-related emergency medicine, including the
conduct of analgesic clinical trials pertinent to
the ED. The recent publication of
consensus-based recommendations for an emergency
medicine pain management curriculum signals
an increased interest in standardizing and
enhancing the role of pain medicine in
emergency medicine residency training [
the American College of Emergency Physicians
has established a new Pain Management
Section, with an inaugural meeting scheduled for
late 2017. The Section’s goals are to promote
further development of the subspecialty of pain
medicine within emergency medicine,
encourage additional research and education around
the ED management of acute and chronic pain
and ultimately develop an emergency medicine
pain management fellowship with official
recognition by the Accreditation Council for
Graduate Medical Education (ACGME).
Although the management of ED pain
continues to challenge emergency physicians and
our practice patterns evolve slowly, these are
encouraging trends within our specialty that
bode well for the future growth of a new
subdiscipline of emergency medicine focused on
the perennial problem of pain.
No funding or sponsorship was received for this
study or publication of this article. The author
meets the International Committee of Medical
Journal Editors (ICMJE) criteria for authorship
for this manuscript, takes responsibility for the
integrity of the work as a whole and has given
final approval for the version to be published.
Disclosures. Knox H. Todd has nothing to
Compliance with Ethics Guidelines. This
article is based on previously conducted studies
and does not involve any new studies of human
or animal subjects performed by any of the
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