Pain management in the emergency department: a clinical review

Pain is one of the most common reasons for patients to visit the emergency department. The ever-growing research on emergency department analgesia has challenged the current practices with respect to the optimal analgesic regimen for acute musculoskeletal pain, safe and judicious opioid prescribing, appropriate utilization of non-opioid therapeutics, and non-pharmacological treatment modalities. This clinical review is set to provide evidence-based answers to these challenging questions.

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Emergency Department Acupuncture for Acute Musculoskeletal Pain Management

Case Medical Research ◽

10.31525/ct1-nct04290741 ◽

2020 ◽

Author(s):

Keyword(s):

Emergency Department ◽

Pain Management ◽

Musculoskeletal Pain

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What is the content of virtually delivered pain management programmes for people with persistent musculoskeletal pain? A systematic review

British Journal of Pain ◽

10.1177/20494637211023074 ◽

2021 ◽

pp. 204946372110230

Author(s):

Gregory Booth ◽

Deborah Williams ◽

Hasina Patel ◽

Anthony W Gilbert

Keyword(s):

Systematic Review ◽

Pain Management ◽

Musculoskeletal Pain ◽

Clinical Guidelines ◽

Reporting Quality ◽

Skills Training ◽

Evidence Based ◽

Core Element ◽

Multidisciplinary Pain Management ◽

Pain Services

Introduction: Virtual consultations (VC) have been embraced by healthcare organisations during the COVID-19 pandemic. VC allows continuation of patient care while adhering to government advised restrictions and social distancing measures. Multidisciplinary pain management programmes (PMPs) are a core element of many pain services and utilising virtual methods to deliver PMPs has allowed them to continue to provide care. This systematic review aimed to explore the content of existing virtually delivered PMPs and discuss if and how these findings can be used to guide clinical delivery. Methods: Eligible studies included adults (aged ⩾18 years) with persistent musculoskeletal pain and any virtually delivered intervention that was described as a PMP or that had components of PMPs. Databases were searched from inception until July 2020. We performed a content analysis comparing existing interventions with established evidence-based clinical guidelines published by the British Pain Society (BPS). Intervention reporting quality was assessed using the Template for Intervention Description and Replication (TIDieR) checklist: an established checklist developed to improve the completeness of the reporting of interventions. Results: Eight studies were included. One intervention included six of the seven components recommended by the BPS; none included all seven. ‘Skills training and activity management’ was present in all eight interventions; ‘education’ and ‘cognitive therapy methods’ were present in six interventions; ‘graded activation’ and ‘methods to enhance acceptance, mindfulness and psychological flexibility’ were present in four interventions; ‘physical exercise’ was present in two interventions and ‘graded exposure’ was present in one intervention. None of the studies described all 12 items of the TIDieR checklist adequately enough for replication. Conclusion: Published virtual PMPs partially meet established clinical guidelines. Future virtual PMPs should be based on evidence-based clinical guidelines, and more research is needed to explore the effectiveness of virtually delivered PMPs and each recommended component.

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P113: Examining emergency physicians’ self-reported opioid prescribing practices for the treatment of acute pain: A Newfoundland perspective

CJEM ◽

10.1017/cem.2020.319 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S105-S106

Author(s):

P. Doran ◽

G. Sheppard ◽

B. Metcalfe

Keyword(s):

Emergency Department ◽

Acute Pain ◽

Oral Morphine ◽

Prescribing Patterns ◽

Evidence Based ◽

Emergency Physicians ◽

Prescribing Practices ◽

Opioid Prescribing ◽

Ensure Patient Safety ◽

Evidence Based Guidelines

Introduction: Canadians are the second largest consumers of prescription opioids per capita in the world. Emergency physicians tend to prescribe stronger and larger quantities of opioids, while family physicians write the most opioid prescriptions overall. These practices have been shown to precipitate future dependence, toxicity and the need for hospitalization. Despite this emerging evidence, there is a paucity of research on emergency physicians’ opioid prescribing practices in Canada. The objectives of this study were to describe our local emergency physicians’ opioid prescribing patterns both in the emergency department and upon discharge, and to explore factors that impact their prescribing decisions. Methods: Emergency physicians from two urban, adult emergency departments in St. John's, Newfoundland were anonymously surveyed using a web-based survey tool. All 42 physicians were invited to participate via email during the six-week study period and reminders were sent at weeks two and four. Results: A total of 21 participants responded to the survey. Over half of respondents (57.14%) reported that they “often” prescribe opioids for the treatment of acute pain in the emergency department, and an equal number of respondents reported doing so “sometimes” at discharge. Eighty-five percent of respondents reported most commonly prescribing intravenous morphine for acute pain in the emergency department, and over thirty-five percent reported most commonly prescribing oral morphine upon discharge. Patient age and risk of misuse were the most frequently cited factors that influenced respondents’ prescribing decisions. Only 4 of the 22 respondents reported using evidence-based guidelines to tailor their opioid prescribing practices, while an overwhelming majority (80.95%) believe there is a need for evidence-based opioid prescribing guidelines for the treatment of acute pain. Sixty percent of respondents completed additional training in safe opioid prescribing, yet less than half of respondents (42.86%) felt they could help to mitigate the opioid crisis by prescribing fewer opioids in the emergency department. Conclusion: Emergency physicians frequently prescribe opioids for the treatment of acute pain and new evidence suggests that this practice can lead to significant morbidity. While further research is needed to better understand emergency physicians’ opioid prescribing practices, our findings support the need for evidence-based guidelines for the treatment of acute pain to ensure patient safety.

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Nurse-initiated oral opioid pain protocol improves the quality of musculoskeletal pain management in the emergency department

International Emergency Nursing ◽

10.1016/j.ienj.2018.07.003 ◽

2019 ◽

Vol 43 ◽

pp. 29-33 ◽

Cited By ~ 1

Author(s):

Sigalit Caspi ◽

Ronit Meidan ◽

Elad Peless ◽

Ela Raizman

Keyword(s):

Emergency Department ◽

Pain Management ◽

Musculoskeletal Pain

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Femoral Nerve Block for Pain Management of Femoral Fractures in the Emergency Department: Evidence Based Topic Review

Hong Kong Journal of Emergency Medicine ◽

10.1177/102490790501200308 ◽

2005 ◽

Vol 12 (3) ◽

pp. 178-181 ◽

Cited By ~ 3

Author(s):

CW Tam ◽

TH Rainer

Keyword(s):

Emergency Department ◽

Pain Management ◽

Nerve Block ◽

Femoral Nerve Block ◽

Femoral Nerve ◽

Femoral Fractures ◽

Evidence Based

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Reduction in Schedule II opioid prescribing by primary care providers, orthopedic and general surgeons, and pain management specialists following the implementation of a State House Bill and an Institutional Controlled Substance Task Force

Journal of Opioid Management ◽

10.5055/jom.2021.0625 ◽

2021 ◽

Vol 17 (2) ◽

pp. 155-167

Author(s):

Lisa B. E. Shields, MD ◽

Timothy A. Johnson, BS ◽

Michael W. Daniels, MS ◽

Alisha Bell, MSN, RN, CPN ◽

Diane M. Siemens, PharmD ◽

...

Keyword(s):

Primary Care ◽

Pain Management ◽

Primary Care Providers ◽

The United States ◽

Prescription Opioid ◽

Evidence Based ◽

Care Providers ◽

Prescribing Practices ◽

Opioid Prescribing ◽

General Surgeons

Objective: Prescription opioid misuse represents a social and economic challenge in the United States. We evaluated Schedule II opioid prescribing practices by primary care providers (PCPs), orthopedic and general surgeons, and pain management specialists.Design: Prospective evaluation of prescribing practices of PCPs, orthopedic and general surgeons, and pain management specialists over 5 years (October 1, 2014-September 30, 2019) in an outpatient setting.Methods: An analysis of Schedule II opioid prescribing following the implementation of federal and state guidelines and evidence-based standards at our institution. Results: There were significantly more PCPs, orthopedic and general surgeons, and pain management specialists with a significantly increased number who prescribed Schedule II opioids, whereas there was a simultaneous significant decline in the average number of Schedule II opioid prescriptions per provider, Schedule II opioid pills prescribed per provider, and Schedule II opioid pills prescribed per patient by providers. The average number of Schedule II opioid prescriptions with a quantity 90 and Opana/Oxycontin prescriptions per PCP, orthopedic surgeon, and pain management specialist significantly decreased. The total morphine milligram equivalent (MME)/day of Schedule II opioids ordered by PCPs, orthopedic and general surgeons, and pain management specialists significantly declined. The ages of the providers remained consistent throughout the study. Conclusions: This study reports the implementation of federal and state regulations and institutional evidence-based guidelines into primary care and medical specialty practices to reduce the number of Schedule II opioids prescribed. Further research is warranted to determine alternative therapies to Schedule II opioids that may alleviate a patient’s pain without initiating or exacerbating a potentially lethal opioid addiction.

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The effect of pain management in reducing limb and spine radiography in stable traumatic patients admitted to the emergency department

Trauma ◽

10.1177/1460408617752206 ◽

2018 ◽

Vol 21 (2) ◽

pp. 107-112 ◽

Cited By ~ 1

Author(s):

Mehdi Torabi ◽

Ali Mehri ◽

Moghaddameh Mirzaei

Keyword(s):

Emergency Department ◽

Patient Satisfaction ◽

Pain Management ◽

Musculoskeletal Pain ◽

Hospital Costs ◽

Primary Outcome Measure ◽

Lower Limbs ◽

Trauma Patients ◽

X Rays ◽

Management Protocol

Introduction Musculoskeletal pain caused by trauma is one of the common complaints of patients referred to the emergency department. Due to the lack of a proper pain control protocol, doctors and nurses do not pay attention to pain, and physicians may tend to request too many radiographs, many of which will be unnecessary. We aimed to study the effect of pain management by fentanyl in reducing the number of radiographs, reducing hospital costs and increasing satisfaction in the patients on patients with isolated trauma in limbs and spine causing musculoskeletal pain. Patients and methods A cohort of patients who were referred to the fast-track emergency department with isolated trauma of the upper and lower limbs or spine and triage levels 3, 4 and 5, were visited twice by an emergency medicine resident – before and after application of a pain management protocol using intravenous fentanyl as the principle analgesic. The primary outcome measure was the reduction in the number of radiographs requested; secondary outcomes included alterations in pain levels and patient satisfaction. Results A total of 158 patients were included in the study. The median age was 27.5 years, three quarters were male and 20.88% had a positive history of opium addiction. The number and costs of diagnostic radiography significantly decreased after the administration of fentanyl (P < 0.0001), as did pain levels measured on visual analogue scale with a consequent increase in patient satisfaction. There were only six complications resulting from fentanyl administration which were mild and transient. Follow-up after 24–72 h, revealed no missed fractures. Conclusions The administration of fentanyl as a strong analgesic as part of an emergency department pain management protocol for trauma patients can be performed with limited minor complications; it can reduce the number of unnecessary X-rays performed, exposure to ionizing radiation and hospital costs as well as improving patient satisfaction without missing fractures.

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