• Neuromuscular Blockade Pain Management
• Acute & Chronic
• Analgesic Drugs
• Trauma
• Critical Care Medicine
• Anesthesiology

• Neuromuscular Blockade
• Emergency Medicine
• Pain Management
• Acute & Chronic
• Analgesic Drugs
• Trauma
• Critical Care Medicine
• Anesthesiology

Pain is the number one patient complaint in the emergency department (ED) [Todd KH et al. J Pain 2007]. James Ducharme, MD, McMaster University, Hamilton, Ontario, Canada, reviewed current recommendations for alleviating patient pain in the ED and improving patients' overall satisfaction. He specifically addressed the pros and cons of low-dose ketamine, nerve blocks, and patient-controlled analgesia (PCA).

Adequate pain relief provides more than just immediate benefits. Relief of acute pain improves quality of life after discharge and reduces the likelihood of developing chronic pain [Daoust R et al. Acad Emerg Med. 2013]. Adequate pain relief also prevents cognitive deterioration in elderly patients, decreases the risk of posttraumatic stress disorder, and, among methadone addicts, reduces the risk of returning to drug abuse. Uncontrolled pain, on the other hand, has been shown to inhibit the immune response and increase the risk of sepsis in critically ill patients.

Opioids are the most effective drugs for severe pain, but they all carry potential for misuse. A study of opioid misuse among discharged ED patients defined misusers as patients who self-escalated their dose, obtained additional opioids without a prescription, or used opioids for a reason other than pain control [Beaudoin FL et al. Am J Emerg Med. 2014]. The study found that 42% of patients misused opioids at either 3 or 30 days. Most of the misuse was because of self-escalation. Key points from the American College of Emergency Physicians clinical policy on opioid prescribing [Cantrill SV et al. Ann Emerg Med. 2012] are shown in Table 1.

Dr Ducharme recommended that emergency physicians who are concerned about opioid misuse discuss their concern directly with the patient, using the Opioid Risk Tool. Physicians who remain uncomfortable prescribing opioids should offer alternatives, such as nonopioid analgesics or nerve blocks.

Low-dose ketamine has emerged as a valuable tool for management of acute pain in a variety of settings. Table 2 summarizes studies of low-dose ketamine for pain.

The use of nerve blocks avoids the systemic effects of pain medication and, when used early after an injury, can prevent wind-up pain and pain after discharge. Table 3 summarizes studies of nerve blocks for pain management.

A randomized trial compared PCA with usual bolus dosing for the control of acute traumatic pain [Rahman NH, DeSilva T. J Emerg Med. 2012] demonstrated that the PCA group experienced faster and greater pain relief. Pain scores (P < .001) and satisfaction ratings were better in the PCA group despite almost identical total morphine dosing.

Another study in patients with acute abdominal pain compared physician-managed analgesia vs PCA [Birnbaum A et al. Acad Emerg Med. 2012]. All patients experienced a decline in mean numeric rating scale (NRS) scores within 30 minutes. However, NRS scores continued to decline up to 120 minutes in PCA patients but not in non-PCA patients (P = .004).

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