The Evolving Landscape of Acute Pain Management in the Era of the Opioid Crisis

Purpose of Review

The purpose of the study is to evaluate and analyze the role of both opioid and non-opioid analgesics in the emergency department (ED).

Recent Findings

Studies have shown that the implementation of opioid-prescribing policies in the ED has the potential to reduce the opioid addiction burden. Clinical studies point to inconsistencies in providers’ approach to pain treatment. In this review, we discuss specific aspects of opioid utilization and explore alternative non-opioid approaches to pain management.

Summary

Pain is the most common reason patients present to the ED. As such, emergency medicine (EM) providers must be well versed in treating pain. EM providers must be comfortable using a wide variety of analgesic medications. Opioid analgesics, while effective for some indications, are associated with significant adverse effects and abuse potential. EM providers should utilize opioid analgesics in a safe and rational manner in an effort to combat the opioid epidemic and to avoid therapeutic misadventures. EM providers should be aware of all of their therapeutic options, e.g., opioid and non-opioid, in order to provide effective analgesia for their patients, while avoiding adverse effects and minimizing the potential for misuse.

     

Evaluation of opioid requirements in the management of renal colic after guideline implementation in the emergency department

PurposeEvaluate opioid prescribing before and after emergency department (ED) renal colic guideline implementation focused on multi-modal pain management.MethodsRetrospective study of ED patients who received analgesia for urolithiasis before and after guideline implementation. The guideline recommends oral acetaminophen, intravenous (IV) ketorolac, and a fluid bolus as first line, IV lidocaine as second line, and opioids as refractory therapy to control pain. Opioid exposure, adverse effects, length of stay (LOS), and ED representation were evaluated. Comparisons were made with univariate analyses. Backwards stepwise binomial multivariate logistic regression to identify factors related to opioid use was performed.ResultsOverall, 962 patients were included (451 pre- and 511 post-implementation). ED and discharge opioid use decreased; 65% vs. 58% and 71% vs. 63% in pre- and post-implementation groups, respectively. More post-implementation patients received non-opioid analgesia (65% vs. 56%) and non-opioid analgesia prior to opioids (50% vs. 38%). A longer ED LOS and higher initial pain score were associated with ED opioid administration. Guideline implementation, receiving non-opioid therapy first, and first renal colic episode were associated with decreased ED opioid administration. Seventeen adverse events (1.8%) were reported. There was no difference in change in ED pain score between groups, but patients in the post-implementation group were admitted more and had a higher 7-day ED representation (11% vs. 7%).ConclusionsA multimodal analgesia protocol for renal colic was associated with decreased opioid prescribing, higher rates of admission to the hospital, and a higher 7-day ED representation rate.     

Addressing the Challenge of Emergency Department Analgesia: Innovation in the Use of Opioid Alternatives

The current epidemic of opioid toxicity and deaths has led clinicians and policy-makers to explore alternatives to opioids for management of moderate to severe pain. One environment in which opioid use has been questioned is the emergency department (ED). This commentary addresses the proposal for “opioid-free EDs” and discusses the risk-to-benefit ratios of opioid and alternative pharmacotherapy for acutely injured patients requiring analgesia. The authors recognize that a truly opioid-free ED is not practical and that alternative analgesic approaches also carry risks. Innovations in managing pain in the ED are needed. But excessive restriction on opioid pharmacotherapy in emergency medicine carries the risk of replacing overprescribing with underprescribing of opioids. The commentary supports the need to establish a core of evidence to support efforts to increase the use of nonopioid and nonpharmacologic modalities for those suffering from pain.     

Changing attitudes about pain and pain control in emergency medicine

Oligoanalgesia continues to be a large problem in the ED. An attitude of suspicion, a culture of ignoring the problem, and an environment that is not conducive to change in practice combine to present formidable obstacles for effective pain management in the emergency setting. Overcoming these obstacles for effective analgesia in the ED is not beyond the capabilities of the individual ED, the emergency physician, or the specialty of emergency medicine. Changing the attitudes of emergency medical providers about pain assessment and management will require attention in several areas of research, education and training. Oligoanalgesia remains a global problem within emergency medicine; however, this awareness is often not felt to be present "in my ED." Individual ownership of the problem may contribute to improvements in pain control. The last 15 years have seen a substantial increase in ED research focused on pain and pain management. Continued research efforts and focused clinical application of these efforts are still required. A better understanding of patient needs and expectations for pain relief, as well as continued efforts at patient education regarding pain, will also improve our treatment of pain in the ED. Recognition by providers of the ethnic, cultural, and gender differences in the expression, reporting, and expectations for treatment of pain should also continue to be a priority in changing attitudes toward pain and pain control. These goals must be realistic within the chaotic and unpredictable environment that defines emergency medicine. Practical and time-sensitive approaches to pain and pain management will continue to bea challenge to enact and enforce in our EDs. The stigma of opioids, in combination with the transient nature of the emergency physician/patient relationship, may be the largest hurdles to overcome for effective pain management not only in the ED, but also following ED discharge. Improvement in provider education of the realities, myths, and misunderstandings of opioid management may provide insight into this problem. The consequences of oligoanalgesia in the ED are not insignificant. To improve our treatment of pain in the ED, a fundamental change in attitude toward pain and the control of pain is required. This is unlikely to occur until pain is adequately addressed and treated appropriately as a true emergency.     

Reduction of Parenteral Opioid Use in Community Emergency Departments Following Implementation of Treatment Guidelines

Objective

Opioid prescribing guidelines are commonly seen as part of the solution to America's opioid epidemic. However, the effectiveness of specific treatment guidelines on altering opioid prescribing in the emergency department (ED) is unclear. We examined provider ordering patterns before and after implementation of opioid use guidelines for ED patients overall and the specific subsets of ED patients with either chronic opioid use or fracture.

Methods

We conducted a pre–post interrupted time series analysis of adult (≥18 years old) ED encounters in 14 integrated community EDs before (2013) and after (2014) the implementation of opioid prescribing guidelines. We compared opioid use pre‐ and postintervention using segmented logistic regression for primary and secondary analyses. The primary outcome was parenteral opioid use in the ED, with additional subgroup analysis of chronic pain and fracture cohorts. We also examined ED oral opioid use and discharge prescribing.

Results

There were 508,337 pre‐ and 531,620 postintervention encounters. The intervention was associated with an initial reduction in the odds of parenteral opioids ordered (odds ratio [OR] = 0.89, 95% CI = 0.87–0.91) and a decrease in the monthly trend compared to the preintervention period (OR = 0.99, 95% CI = 0.99–0.99). The immediate reduction in parenteral opioid use was significantly larger in the cohort of patients with chronic pain (OR = 0.81, 95% CI = 0.72–0.91), whereas the fracture cohort showed no change (OR = 1.10, 95% CI = 0.97–1.25).

Conclusion

The use of an opioid ordering guideline was associated with significant reduction in parenteral opioid use in the ED and as intended subgroup comparisons suggest that acute fractures were not affected and chronic pain visits were associated with larger decreases in opioid use.

     

Opioid Prescribing for Chronic Pain in Federally Qualified Health Centers Post–Centers for Disease Control and Prevention Guidelines

This study provides important insight on the demographic characteristics, knowledge, practices, and perceptions of primary care providers (PCPs) prescribing opioids to patients at federally qualified health centers (FQHCs). Findings suggest that FQHCs would benefit from examining their current pain management policies and practices and addressing issues as they arise. FQHCs need to provide continuing education on pain management for PCPs and partner with external organizations and social service agencies to facilitate patient use of recommended alternative pain treatments. Future research should examine the efficacy of such strategies for improving opioid prescribing practices among PCPs at FQHCs.     

Emergency Nurse Perceptions of Pain and Opioids in the Emergency Department

The opioid crisis is a national health emergency with immense morbidity, mortality, and socioeconomic cost. Emergency department (ED) pain management is tightly linked to the issue of opioid use disorder (OUD), because opioid exposure is necessary for development of OUD. Emergency nurses are on the frontlines of this complex problem, yet little, if any, attention has been paid to the role they play in the prevention and management of either pain or OUD in this unique and important setting. A framework that conceptualizes and optimizes emergency nurses as change agents in the opioid epidemic is urgently needed. While ED pain management and OUD prevention is dependent on the entire care team, this innovative study qualitatively characterizes emergency nurse perceptions of pain management, OUD prevention, and their potential role in each. Content analysis produced 14 categories that were clustered into two themes, “nurses influence ED pain management” and “adjustments in ED pain management”, and an overarching message that “pain management depends on the care team.” By generating a more comprehensive and nuanced understanding of the role played by emergency nurses, our findings provide essential insights into potential interventions and frameworks.     

Australian management strategies for oral opioid use in non-malignant pain

Chronic non-cancer pain is a complex biopsychosocial phenomenon; as such it is unlikely that any one treatment modality will achieve relief. There is increasing availability of oral opioid preparations and an associated increased level of prescribing; consequently in 1997 the Australian Pain Society drew up some management strategies for their use. This paper reviews the principles of those strategies, stressing that oral opioids should not be used in isolation nor used to treat 'distress' often associated with chronic pain. The place of a trial of opioid and informed consent are discussed.