Randomized clinical trial of efficacy and safety of a single 2-mg intravenous dose of hydromorphone versus usual care in the management of acute pain

Bedside Evaluation of Early VAS/NRS Based Protocols for Intravenous Morphine in the Emergency Department: Reasons for Poor Follow-Up and Targeted Practices

Intravenous (IV) morphine protocols based on patient-reported scores, immediately at triage, are recommended for severe pain in Emergency Departments. However, a low follow-up is observed. Scarce data are available regarding bedside organization and pain etiologies to explain this phenomenon. The objective was the real-time observation of motivations and operational barriers leading to morphine avoidance. In a single French hospital, 164 adults with severe pain at triage were included in a cross-sectional study of the prevalence of IV morphine titration; caregivers were interviewed by real-time questionnaires on “real” reasons for protocol avoidance or failure. IV morphine prevalence was 6.1%, prescription avoidance was mainly linked to “Pain reassessment” (61.0%) and/or “alternative treatment prioritization” (49.3%). To further evaluate the organizational impact on prescription decisions, a parallel assessment of “simulated” prescription conditions was simultaneously performed for 98/164 patients; there were 18 titration decisions (18.3%). Treatment prioritization was a decision driver in the same proportion, while non-eligibility for morphine was more frequently cited (40.6% p = 0.001), with higher concerns about pain etiologies. Anticipation of organizational constraints cannot be excluded. In conclusion, IV morphine prescription is rarely based on first pain scores. Triage assessment is used for screening by bedside physicians, who prefer targeted practices to automatic protocols.

Patient-Reported outcomes of pain care research in the adult emergency department: A scoping review

Despite more than 30 years of research, pain in the emergency department (ED) setting is frequently undertreated. EDs prioritise process measures that often have tenuous links to patient-reported outcomes. However, process measures, such as time to the administration of first analgesic medication, are neither direct objective measures of analgesia nor appropriate surrogate markers of pain relief. Since pain is a subjective symptom that lacks an objective measure, pain research in any clinical environment, including EDs, should rely upon patient-reported outcomes. This scoping review examined patient-reported outcomes (PROs) and patient-reported outcome measures (PROMs) of pain care in the adult emergency department at the micro, meso and macro-level over the last ten years. We reviewed pain care research conducted on adults in EDs over the last ten years and identified 57 articles using 14 patient-reported outcomes of pain care falling into five broad areas, most without validation or adaption to the ED setting. Despite efforts made to incorporate PROs and PROMs into acute pain care research in the ED over the last ten years, there is still no gold-standard PROM in widespread use. We recommend the adaptation of existing tools with rigorous validation in ED populations.

Randomized Clinical Trial of Intravenous (IV) Acetaminophen as an Adjunct to IV Hydromorphone for Acute Severe Pain in Emergency Department Patients

BACKGROUND

A fundamental challenge for emergency department (ED) clinicians is to relieve severe, acute pain while simultaneously avoiding adverse events associated with opioid analgesics. Because there is evidence that intravenous (IV) acetaminophen is an effective adjuvant analgesic in postoperative settings, we examined whether it also has a role in the ED.

METHODS

This was a two-arm, double-blind randomized clinical trial. All patients received 1 mg of IV hydromorphone. Patients were then randomized to receive 1 g of IV acetaminophen or placebo. The primary outcome was the between-group difference in change in pain from baseline (before treatment) to 60 minutes after administration of study drugs, measured on an 11-point numeric rating scale (NRS).

RESULTS

Of 828 patients screened, 162 were enrolled and 159 had the primary outcome. Patients allocated to acetaminophen + hydromorphone had a mean decline in pain from baseline to 60 minutes of 6.2 NRS units; those receiving placebo + hydromorphone had a mean decline of 5.4, a difference of 0.8 NRS units (95% confidence interval [CI] = -0.01 to 1.8). Two patients in each group received additional analgesics in the first 60 minutes of the study. At 120 minutes the NRS pain difference was 0.6 (95% CI = -0.4 to 1.6). A total of 26.9% of patients who received acetaminophen wanted more analgesia versus 37.7% of those given placebo (difference = -10.8%, 95% CI = -24.3% to 4.4%). The incidence of adverse effects was similar in both groups.

CONCLUSIONS

The addition of 1 g of IV acetaminophen to 1 mg of IV hydromorphone provided neither clinically meaningful nor statistically superior analgesia than hydromorphone alone.

Emergency Providers' Pain Management in Patients Transferred to Intensive Care Unit for Urgent Surgical Interventions

Introduction

Pain is the most common complaint for an emergency department (ED) visit, but ED pain management is poor. Reasons for poor pain management include providers’ concerns for drug-seeking behaviors and perceptions of patients’ complaints. Patients who had objective findings of long bone fractures were more likely to receive pain medication than those who did not, despite pain complaints. We hypothesized that patients who were interhospital-transferred from an ED to an intensive care unit (ICU) for urgent surgical interventions would display objective pathology for pain and thus receive adequate pain management at ED departure.

Methods

This was a retrospective study at a single, quaternary referral, academic medical center. We included non-trauma adult ED patients who were interhospital-transferred and underwent operative interventions within 12 hours of ICU arrival between July 2013 and June 2014. Patients who had incomplete ED records, required invasive mechanical ventilation, or had no pain throughout their ED stay were excluded. Primary outcome was the percentage of patients at ED departure achieving adequate pain control of ≤ 50% of triage level. We performed multivariable logistic regression to assess association between demographic and clinical variables with inadequate pain control.

Results

We included 112 patients from 39 different EDs who met inclusion criteria. Mean pain score at triage and ED departure was 8 (standard deviation 8 and 5 [3]), respectively. Median of total morphine equivalent unit (MEU) was 7.5 [5–13] and MEU/kg total body weight (TBW) was 0.09 [0.05–0.16] MEU/kg, with median number of pain medication administration of 2 [1–3] doses. Time interval from triage to first narcotic dose was 61 (35–177) minutes. Overall, only 38% of patients achieved adequate pain control. Among different variables, only total MEU/kg was associated with significant lower risk of inadequate pain control at ED departure (adjusted odds ratio = 0.22; 95% confidence interval = 0.05–0.92, p = 0.037).

Conclusion

Pain control among a group of interhospital-transferred patients requiring urgent operative interventions, was inadequate. Neither demographic nor clinical factors, except MEU/kg TBW, were shown to associate with poor pain management at ED departure. Emergency providers should consider more effective strategies, such as multimodal analgesia, to improve pain management in this group of patients.

Endogenous opiates and behavior: 2013

This paper is the thirty-sixth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2013 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.

Randomized clinical trial of an intravenous hydromorphone titration protocol versus usual care for management of acute pain in older emergency department patients

BACKGROUND AND OBJECTIVES

Opioid titration is an effective strategy for treating pain; however, titration is generally impractical in the busy emergency department (ED) setting. Our objective was to test a rapid, two-step, hydromorphone titration protocol against usual care in older patients presenting to the ED with acute severe pain.

METHODS

This was a prospective, randomized clinical trial of patients 65 years of age and older presenting to an adult, urban, academic ED with acute severe pain. The study was registered at http://www.clinicaltrials.gov (NCT01429285). Patients randomized to the hydromorphone titration protocol initially received 0.5 mg intravenous hydromorphone. Patients randomized to usual care received any dose of any intravenous opioid. At 15 min, patients in both groups were asked, 'Do you want more pain medication?' Patients in the hydromorphone titration group who answered 'yes' received a second dose of 0.5 mg intravenous hydromorphone. Patients in the usual care group who answered 'yes' had their ED attending physician notified, who then could administer any (or no) additional medication. The primary efficacy outcome was satisfactory analgesia defined a priori as the patient declining additional analgesia at least once when asked at 15 or 60 min after administration of the initial opioid. Dose was calculated in morphine equivalent units (MEU: 1 mg hydromorphone = 7 mg morphine). The need for naloxone to reverse adverse opioid effects was the primary safety outcome.

RESULTS

83.0 % of 153 patients in the hydromorphone titration group achieved satisfactory analgesia compared with 82.5 % of 166 patients in the usual care group (p = 0.91). Patients in the hydromorphone titration group received lower mean initial doses of opioids at baseline than patients in the usual care group (3.5 MEU vs. 4.7 MEU, respectively; p ≤ 0.001) and lower total opioids through 60 min (5.3 MEU vs. 6.0 MEU; p = 0.03). No patient needed naloxone.

CONCLUSIONS

Low-dose titration of intravenous hydromorphone in increments of 0.5 mg provides comparable analgesia to usual care with less opioid over 60 min.

Management of Pain in the Emergency Department

Since pain is a primary impetus for patient presentation to the Emergency Department (ED), its treatment should be a priority for acute care providers. Historically, the ED has been marked by shortcomings in both the evaluation and amelioration of pain. Over the past decade, improvements in the science of pain assessment and management have combined to facilitate care improvements in the ED. The purpose of this review is to address selected topics within the realm of ED pain management. Commencing with general principles and definitions, the review continues with an assessment of areas of controversy and advancing knowledge in acute pain care. Some barriers to optimal pain care are discussed, and potential mechanisms to overcome these barriers are offered. While the review is not intended as a resource for specific pain conditions or drug information, selected agents and approaches are mentioned with respect to evolving evidence and areas for future research.