Clinical Review

Appropriate Analgesic Use in the Emergency Department

Emergency Medicine. 2014 June;46(6):248-255

References

Todd KH. Pain assessment instruments for use in the emergency department. Emerg Med Clin North Am. 2005;23(2):285-295.
Cordell WH, Keene KK, Giles BK, Jones JB, Jones JH, Brizendine EJ. The high prevalence of pain in emergency medical care. Am J Emerg Med. 2002;20(3):165-169.
Tcherny-Lessenot S, Karwowski-Soulié F, Lamarche-Vadel A, Ginsburg C, Brunet F, Vidal-Trecan G. Management and relief of pain in an emergency department from the adult patients’ perspective. J Pain Symptom Manage. 2003;25(6):539-546.
Karwowski-Soulié F, Lessenot-Tcherny S, Lamarche-Vadel A, et al. Pain in an emergency department: an audit. Eur J Emerg Med. 2006;13(4):218-224.
Fosnocht DE, Swanson ER, Barton ED. Changing attitudes about pain and pain control in emergency medicine. Emerg Med Clin North Am. 2005;23(2):297-306.
Wilson JE, Pendelton JM. Oligoanalgesia in the emergency department. Am J Emerg Med. 1989;7(6):620-623.
Meghani SH, Byun E, Gallagher RM. Time to take stock: a meta-analysis and systemic review of analgesic treatment disparities for pain in the United States. Pain Med. 2012;13(2):150-174.
Johnston LD, O’Malley PM, Miech RA, Bachman JG, Schutenberg JE; The University of Michigan Institute for Social Research. Monitoring the future: 2013 overview key findings of on adolescent drug use. http://www.monitoringthefuture.org/pubs/monographs/mtf-overview2013.pdf. Accessed June 6, 2014.
Manchikanti L, Fellow B, Ailinani H, Pampati V. Therapeutic use, abuse, and nonmedical use of opioids: a ten year perspective. Pain Physician. 2010;13(5):401-435.
Silka PA, Roth MM, Moreno G, Merrill L, Geiderman JM. Pain scores improve analgesic administration patterns for trauma patients in the emergency department. Acad Emerg Med. 2004;11(3):264-270.
Nelson BP, Cohen D, Lander O, Crawford N, Viccellio AW, Singer AJ. Mandated pain scales improve frequency of ED analgesic administration. Am J Emerg Med. 2004;22(7):582-585.
World Health Organization. Cancer pain relief with a guide to opioid availability 2^nd ed. 1996. http://whqlibdoc.who.int/publications/9241544821.pdf. Accessed June 6, 2014.
Grosser T, Smyth EM, FitzGerald GA. Anti-inflammatory, antipyretic, and analgesic agents: pharmacotherapy of gout. In: Brunton LL, Chabner BA, Knollman BC, eds. Goodman and Gilman’s The Pharmacological Basis of Therapeutics. 12^th ed. China: The McGraw Hill Companies; 2011:959-1004.
Scialli AR, Ang R, Breitmeyer J, Royal MA. A review of the literature on the effects of acetaminophen on pregnancy outcome. Reprod Toxicol. 2010;30(4):495-507.
Schilling A, Corey R, Leonard M, Eghtesad B. Acetaminophen: old drug, new warnings. Cleveland Clin J Med. 2010;77(1):19-27.
Shrestha M, Singh R, Moreden J, Hayes JE. Ketorolac vs chlorpromazine in the treatment of acute migraine without aura. A prospective, randomized, double-blind trial. Arch Intern Med.1996;156(15):1725-1728.
Turkewitz LJ, Casaly JS, Dawson GA, Wirth O, Hurst RJ, Gillette PL. Self-administration of parenteral ketorolac tromethamine for head pain. Headache. 1992;32(9):452-454.
Larkin GL, Peacock WF 4th, Pearl SM, Blair GA, D’Amico F. Efficacy of ketorolac tromethamine versus meperidine in the ED treatment of acute renal colic. Am J Emerg Med. 1999;17(1):6-10.
Yaksh TL, Wallace MS. Opiods, analgesia and pain management. In: Brunton LL, Chabner BA, Knollman BC, eds. Goodman and Gilman’s The Pharmacological Basis of Therapeutics. 12^th ed. China: The McGraw Hill Companies; 2011:481-526.
DeSandre PL, Quest TE. Management of cancer-related pain. Hematol Oncol Clin N Am. 2010;24(3):643-658.

Again, the purpose of the ladder is not to provide a strict protocol for adherence, but rather to provide a reasonable starting point as a guide to the clinician. The key to its successful use is reassessment of the patient to determine if adequate pain relief is achieved.

Routes of Administration

Before reviewing the individual medications available, it is important to first discuss the routes of administration, each of which has advantages and disadvantages (Table 1). For severe pain, most experts agree it is best to titrate the analgesic chosen to effect; this means employing the IV route. In cases of mild pain, the oral route should be used whenever possible; this route is effective, efficient, and much less expensive than parenterally administered analgesics. With respect to moderate and severe pain, individual circumstances will help determine the most appropriate route.

Acetaminophen

Acetaminophen, the active ingredient in Tylenol, was first marketed in the United States in 1955 as an antipyretic and pain reliever.¹³ It is a synthetic centrally acting analgesic that is metabolized in the liver. Acetaminophen has been used alone or in combination in hundreds of formulations to treat a wide variety of pain and fever-related conditions. In the ED setting, acetaminophen is frequently used as an antipyretic and—either alone or in combination with opioids—for oral pain control.

Acetaminophen is very well tolerated by most patients, with minimal gastrointestinal (GI) distress. It is inexpensive, and the wide variety of formulations (eg, liquid, tablet, suppository) make it useful in a number of clinical scenarios. Acetaminophen is generally considered to be the only nonopioid analgesic that is safe in pregnancy,¹⁴ and it has no sedative or addictive effects.

There are, however, some disadvantages to using acetaminophen. Concerns about its safety and accidental overdose have recently led to the introduction of a 4,000-mg maximum daily dose recommendation¹⁵ and heightened concern over using multiple medications containing acetaminophen. In January 2014, the US Food and Drug Administration recommended that no combination medication contain more than 325 mg of acetaminophen because of the risk of toxicity when multiple drugs containing acetaminophen are consumed.

In addition to concerns of inadvertent overdose, another disadvantage of acetaminophen is that while it may be an effective antipyretic and analgesic, it has little or no anti-inflammatory properties. Therefore, in cases requiring an anti-inflammatory agent, an NSAID, when appropriate, would be the more effective option.

NSAIDs

Nonsteroidal anti-inflammatory drugs function by inhibiting prostaglandin production in the cyclooxygenase 1 and 2 (COX-1 and COX-2) pathways. Ibuprofen, indomethacin, ketorolac, naproxen, and other NSAIDs are chiefly utilized to control pain, inflammation, and fever via the oral route. As production of various prostaglandins via the COX-2 pathway is thought to contribute to fever, inflammation, and pain, inhibition of this pathway by NSAIDs can help alleviate these symptoms. The COX-1 pathway contributes many factors important to the protection and health of the GI tract, and inhibition of this pathway can lead to GI distress and damage. Unfortunately, the most commonly used and available NSAIDs inhibit both COX pathways simultaneously, and in doing so, prompt the GI symptoms which are the most common adverse side effects of therapy. In addition to GI effects of the COX-1 and COX-2 inhibitors, there are also concerns over the associated antiplatelet effects in patients undergoing surgery or potentially suffering from occult or intracranial bleeding.¹³

Ibuprofen
This is the most commonly used NSAID in the United States and is available without a prescription. Ibuprofen is typically used to treat mild-to-moderate pain from a musculoskeletal or inflammatory source. As an oral nonprescription medication, it can be used advantageously to treat acute pain in the ED and continued in the outpatient setting. Ibuprofen is neither sedating nor addicting, with a rapid onset of action and a plasma half-life of approximately 2 hours.¹³ However, there is a dose-dependent feature which allows large doses (eg, 800 mg) to be spaced-out every 8 hours while maintaining effective analgesia. Typical doses range from 200 mg to 800 mg orally every 6 to 8 hours, with a maximum dose of 3.2 g/d. Patients should be instructed to take each dose with a meal or snack to help alleviate GI side effects.

The greatest advantage of ibuprofen and other NSAIDs is their effect on inflammation and the ability to treat the inflammatory cause of pain—not just the symptom. Nonsteroidal anti-inflammatory drugs are well tolerated by most patients and can be obtained without prescription at low cost. Additionally, doses of ibuprofen and acetaminophen can be alternated.

Ketorolac
Often marketed as Toradol, ketorolac is a powerful NSAID available in IV, IM, and oral formulations. Typical doses are 30 mg IV, 60 mg IM, or 10 mg orally every 4 to 6 hours (maximum of 40 mg/d). The basic pharmacology and mechanism of action of ketorolac are similar to ibuprofen. Though ketorolac is useful to treat more severe pain, it should only be used for short-term management of pain (ie, 5 days or less). Ketorolac is often used for postoperative pain, but also is helpful for pain control in patients using opioids. It has been shown to be effective for acute renal colic and can also provide relief for migraine headaches.^16,17 In a direct comparison between ketorolac and meperidine (Demerol) for patients suffering from renal stones, ketorolac was found to be more effective and provide longer lasting pain relief.¹⁸

References

Todd KH. Pain assessment instruments for use in the emergency department. Emerg Med Clin North Am. 2005;23(2):285-295.
Cordell WH, Keene KK, Giles BK, Jones JB, Jones JH, Brizendine EJ. The high prevalence of pain in emergency medical care. Am J Emerg Med. 2002;20(3):165-169.
Tcherny-Lessenot S, Karwowski-Soulié F, Lamarche-Vadel A, Ginsburg C, Brunet F, Vidal-Trecan G. Management and relief of pain in an emergency department from the adult patients’ perspective. J Pain Symptom Manage. 2003;25(6):539-546.
Karwowski-Soulié F, Lessenot-Tcherny S, Lamarche-Vadel A, et al. Pain in an emergency department: an audit. Eur J Emerg Med. 2006;13(4):218-224.
Fosnocht DE, Swanson ER, Barton ED. Changing attitudes about pain and pain control in emergency medicine. Emerg Med Clin North Am. 2005;23(2):297-306.
Wilson JE, Pendelton JM. Oligoanalgesia in the emergency department. Am J Emerg Med. 1989;7(6):620-623.
Meghani SH, Byun E, Gallagher RM. Time to take stock: a meta-analysis and systemic review of analgesic treatment disparities for pain in the United States. Pain Med. 2012;13(2):150-174.
Johnston LD, O’Malley PM, Miech RA, Bachman JG, Schutenberg JE; The University of Michigan Institute for Social Research. Monitoring the future: 2013 overview key findings of on adolescent drug use. http://www.monitoringthefuture.org/pubs/monographs/mtf-overview2013.pdf. Accessed June 6, 2014.
Manchikanti L, Fellow B, Ailinani H, Pampati V. Therapeutic use, abuse, and nonmedical use of opioids: a ten year perspective. Pain Physician. 2010;13(5):401-435.
Silka PA, Roth MM, Moreno G, Merrill L, Geiderman JM. Pain scores improve analgesic administration patterns for trauma patients in the emergency department. Acad Emerg Med. 2004;11(3):264-270.
Nelson BP, Cohen D, Lander O, Crawford N, Viccellio AW, Singer AJ. Mandated pain scales improve frequency of ED analgesic administration. Am J Emerg Med. 2004;22(7):582-585.
World Health Organization. Cancer pain relief with a guide to opioid availability 2^nd ed. 1996. http://whqlibdoc.who.int/publications/9241544821.pdf. Accessed June 6, 2014.
Grosser T, Smyth EM, FitzGerald GA. Anti-inflammatory, antipyretic, and analgesic agents: pharmacotherapy of gout. In: Brunton LL, Chabner BA, Knollman BC, eds. Goodman and Gilman’s The Pharmacological Basis of Therapeutics. 12^th ed. China: The McGraw Hill Companies; 2011:959-1004.
Scialli AR, Ang R, Breitmeyer J, Royal MA. A review of the literature on the effects of acetaminophen on pregnancy outcome. Reprod Toxicol. 2010;30(4):495-507.
Schilling A, Corey R, Leonard M, Eghtesad B. Acetaminophen: old drug, new warnings. Cleveland Clin J Med. 2010;77(1):19-27.
Shrestha M, Singh R, Moreden J, Hayes JE. Ketorolac vs chlorpromazine in the treatment of acute migraine without aura. A prospective, randomized, double-blind trial. Arch Intern Med.1996;156(15):1725-1728.
Turkewitz LJ, Casaly JS, Dawson GA, Wirth O, Hurst RJ, Gillette PL. Self-administration of parenteral ketorolac tromethamine for head pain. Headache. 1992;32(9):452-454.
Larkin GL, Peacock WF 4th, Pearl SM, Blair GA, D’Amico F. Efficacy of ketorolac tromethamine versus meperidine in the ED treatment of acute renal colic. Am J Emerg Med. 1999;17(1):6-10.
Yaksh TL, Wallace MS. Opiods, analgesia and pain management. In: Brunton LL, Chabner BA, Knollman BC, eds. Goodman and Gilman’s The Pharmacological Basis of Therapeutics. 12^th ed. China: The McGraw Hill Companies; 2011:481-526.
DeSandre PL, Quest TE. Management of cancer-related pain. Hematol Oncol Clin N Am. 2010;24(3):643-658.

Appropriate Analgesic Use in the Emergency Department

References

Routes of Administration

Acetaminophen

NSAIDs

Pages

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