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Gaul E, Barbour T, Nowacki AS, Mace SE. Intranasal Ketorolac for Acute Pain in Adult Emergency Department Patients. West J Nurs Res 2022; 44:1047-1056. [PMID: 34369237 DOI: 10.1177/01939459211030336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Pain is a common complaint in the emergency department. An alternative to opioids is desirable. Oral medications are not feasible with gastrointestinal disorders or NPO. Intravenous medications require skill and time. Intravenous/intramuscular medications are painful with potential needlestick injury. Intranasal medications have rapid onset, easy administration, do not need skilled providers, and no risk of needlestick injury. A total of 28 adults with acute pain (numeric rating scale ≥ 4) received intranasal ketorolac. Numeric rating scale decreased in all: 32% complete pain relief, median (interquartile range) decrease -5 (-6.8 to -4) (p < .001). Pain relief onset was median [interquartile range] 5 (2.3, 15.0) min. Vital signs remained normal. There were no nasal mucosal changes, no complications. Minor side effects, mostly nasal burning, in 43%, resolved within 5 min. Patients and nurses were satisfied with intranasal ketorolac, and would use it again. Intranasal ketorolac had a rapid onset, was effective, safe, well tolerated with minor side effects that resolved quickly.
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Affiliation(s)
- Elizabeth Gaul
- Emergency Services Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tracy Barbour
- Emergency Services Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy S Nowacki
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Medicine, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, OH, USA
| | - Sharon E Mace
- Department of Emergency Medicine, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, MetroHealth Medical Center/Cleveland Clinic Emergency Medicine Residency, Emergency Services Institute, Cleveland, OH, USA
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Ruskin D, Rasul R, McCann-Pineo M. Predictors of Emergency Department Opioid Use Among Adolescents and Young Adults. Pediatr Emerg Care 2022; 38:e1409-e1416. [PMID: 35686972 PMCID: PMC9351695 DOI: 10.1097/pec.0000000000002777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE It is well established that adolescents and young adults are increasingly vulnerable to the effects of early opioid exposures, with the emergency department (ED) playing a critical role in such introduction. Our objective was to identify predictors of ED opioid administration (ED-RX) and prescribing at discharge (DC-RX) among adolescent and young adults using a machine learning approach. METHODS We conducted a secondary analysis of ED visit data from the National Hospital Ambulatory Medical Care Survey from 2014 to 2018. Visits where patients were aged 10 to 24 years were included. Predictors of ED-RX and DC-RX were identified via machine learning methods. Separate weighted logistic regressions were performed to determine the association between each predictor, and ED-RX and DC-RX, respectively. RESULTS There were 12,693 ED visits identified within the study time frame, with the majority being female (58.6%) and White (70.7%). Approximately 12.3% of all visits were administered an opioid during the ED visit, and 11.5% were prescribed one at discharge. For ED-RX, the strongest predictors were fracture injury (odds ratio [OR], 5.24; 95% confidence interval [CI], 3.73-7.35) and Southern geographic region (OR, 3.01; 95% CI, 2.14-4.22). The use of nonopioid analgesics significantly reduced the odds of ED-RX (OR, 0.46; 95% CI, 0.37-0.57). Fracture injury was also a strong predictor of DC-RX (OR, 5.91; 95% CI, 4.24-8.25), in addition to tooth pain (OR, 5.47; 95% CI, 3.84-7.69). CONCLUSIONS Machine learning methodologies were able to identify predictors of ED-RX and DC-RX, which can be used to inform ED prescribing guidelines and risk mitigation efforts among adolescents and young adults.
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Tsze DS, Lubell TR, Carter RC, Chernick LS, DePeter KC, McLaren SH, Kwok MY, Roskind CG, Gonzalez AE, Fan W, Babineau SE, Friedman BW, Dayan PS. Intranasal ketorolac versus intravenous ketorolac for treatment of migraine headaches in children: A randomized clinical trial. Acad Emerg Med 2022; 29:465-475. [PMID: 34822214 PMCID: PMC10695685 DOI: 10.1111/acem.14422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/31/2021] [Accepted: 11/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intravenous ketorolac is commonly used for treating migraine headaches in children. However, the prerequisite placement of an intravenous line can be technically challenging, time-consuming, and associated with pain and distress. Intranasal ketorolac may be an effective alternative that is needle-free and easier to administer. We aimed to determine whether intranasal ketorolac is non-inferior to intravenous ketorolac for reducing pain in children with migraine headaches. METHODS We conducted a randomized double-blind non-inferiority clinical trial. Children aged 8-17 years with migraine headaches, moderate to severe pain, and requiring parenteral analgesics received intranasal ketorolac (1 mg/kg) or intravenous ketorolac (0.5 mg/kg). Primary outcome was reduction in pain at 60 min after administration measured using the Faces Pain Scale-Revised (scored 0-10). Non-inferiority margin was 2/10. Secondary outcomes included time to onset of clinically meaningful decrease in pain; ancillary emergency department outcomes (e.g. receipt of rescue medications, headache relief, headache freedom, percentage improvement); 24-h follow-up outcomes; functional disability; and adverse events. RESULTS Fifty-nine children were enrolled. We analyzed 27 children who received intranasal ketorolac and 29 who received intravenous ketorolac. The difference in mean pain reduction at 60 min between groups was 0.2 (95% CI -0.9, 1.3), with the upper limit of the 95% CI being less than the non-inferiority margin. There were no statistical differences between groups for secondary outcomes. CONCLUSIONS Intranasal ketorolac was non-inferior to intravenous ketorolac for reducing migraine headache pain in the emergency department.
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Affiliation(s)
- Daniel S. Tsze
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Tamar R. Lubell
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Robert C. Carter
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Lauren S. Chernick
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Kerrin C. DePeter
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Son H. McLaren
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Maria Y. Kwok
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Cindy G. Roskind
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Ariana E. Gonzalez
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Weijia Fan
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Shannon E. Babineau
- Departments of Pediatrics and Neurology, Sidney Kimmel Medical College of Thomas Jefferson University, Morristown, New Jersey, USA
| | - Benjamin W. Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Peter S. Dayan
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Opioid Analgesics and Persistent Pain After an Acute Pain Emergency Department Visit: Evidence from a Cohort of Suspected Urolithiasis Patients. J Emerg Med 2021; 61:637-648. [PMID: 34690022 DOI: 10.1016/j.jemermed.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/19/2021] [Accepted: 09/11/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Severe acute pain is still commonly treated with opioid analgesics in the United States, but this practice could prolong the duration of pain. OBJECTIVES Estimate the risk of experiencing persistent pain after opioid analgesic use after emergency department (ED) discharge among patients with suspected urolithiasis. METHODS We analyzed data collected for a longitudinal, multicenter clinical trial of ED patients with suspected urolithiasis. We constructed multilevel models to estimate the odds ratios (ORs) of reporting pain at 3, 7, 30, or 90 days after ED discharge, using multiple imputation to account for missing outcome data. We controlled for clinical, demographic, and institutional factors and used weighting to account for the propensity to be prescribed an opioid analgesic at ED discharge. RESULTS Among 2413 adult ED patients with suspected urolithiasis, 62% reported persistent pain 3 days after discharge. Participants prescribed an opioid analgesic at discharge were OR 2.51 (95% confidence interval [CI] 1.82-3.46) more likely to report persistent pain than those without a prescription. Those who reported using opioid analgesics 3 days after discharge were OR 2.24 (95% CI 1.77-2.84) more likely to report pain at day 7 than those not using opioid analgesics at day 3, and those using opioid analgesics at day 30 had OR 3.25 (95% CI 1.96-5.40) greater odds of pain at day 90. CONCLUSIONS Opioid analgesic prescription doubled the odds of persistent pain among ED patients with suspected urolithiasis. Limiting opioid analgesic prescribing at ED discharge for these patients might prevent persistent pain in addition to limiting access to these medications.
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Eucker SA, Manandhar P, Arulraja K, Agnihotri D, Pollack CV, Freiermuth C. Higher daily pain severity after emergency department visits is associated with lower return-to-work rates. Am J Emerg Med 2021; 45:48-53. [PMID: 33657503 DOI: 10.1016/j.ajem.2021.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pain can impair functional status, including a patient's ability to return to work. The purpose of this study was to determine whether there was an association between pain levels and return-to-work status during the first 4 days post-ED discharge in ED patients seen for undifferentiated acute pain. METHODS This secondary analysis of data from the Acute Management of Pain from the Emergency Department (AMPED) registry included patients who reported working either full-time or part-time. We used Cox regression models to examine the association between daily self-reported minimum and maximum pain scores and first return to work. We used repeated measures logistic regression models to examine the association between daily minimum and maximum pain scores and daily return-to-work status. RESULTS Of the 610 employed patients, 481 (78.9%) were employed full-time and 129 (21.1%) part-time. The average delay in returning to work after ED visit was 2.4 days. For all models, higher minimum and maximum daily pain scores predicted lower daily return-to-work rates in the first four days post-ED discharge. The adjusted hazards ratios for first return to work were 0.91 (0.87, 0.96) and 0.93 (0.89, 0.97), while the adjusted odds ratios for daily return-to-work status were 0.80 (0.75, 0.85) and 0.88 (0.83, 0.93) for every one-point increase in minimum and maximum pain scores, respectively. CONCLUSION Higher daily pain severity is associated with decreased return-to-work after ED visits for acute pain, highlighting the importance of adequate discharge pain management from the ED.
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Affiliation(s)
- Stephanie A Eucker
- Duke University, Department of Surgery, Division of Emergency Medicine, United States of America.
| | | | - Kami Arulraja
- Duke University, Department of Surgery, Division of Emergency Medicine, United States of America
| | - Deepti Agnihotri
- Duke University, Department of Surgery, Division of Emergency Medicine, United States of America
| | - Charles V Pollack
- University of Mississippi School of Medicine, Department of Emergency Medicine, United States of America
| | - Caroline Freiermuth
- University of Cincinnati, Department of Emergency Medicine, United States of America
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Kim HS, Courtney DM, McCarthy DM, Cella D. Patient-reported Outcome Measures in Emergency Care Research: A Primer for Researchers, Peer Reviewers, and Readers. Acad Emerg Med 2020; 27:403-418. [PMID: 31945245 DOI: 10.1111/acem.13918] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/04/2020] [Accepted: 01/06/2020] [Indexed: 01/07/2023]
Abstract
Patient-reported outcomes (PROs) are of increasing importance in clinical research because they capture patients' experience with well-being, illness, and their interactions with health care. Because PROs tend to focus on specific symptoms (e.g., pain, anxiety) or general assessments of patient functioning and quality of life that offer unique advantages compared to traditional clinical outcomes (e.g., mortality, emergency department revisits), emergency care researchers may benefit from incorporation of PRO measures into their research design as a primary or secondary outcome. Patients may also benefit from the ability of PROs to inform clinical practice and facilitate patient decision making, as PROs are obtained directly from the lived experience of other patients with similar conditions or health status. This review article introduces and defines key terminology relating to PROs, discusses reasons for utilizing PROs in clinical research, outlines basic psychometric and practical assessments that can be used to select a specific PRO measure, and highlights examples of commonly utilized PRO measures in emergency care research.
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Affiliation(s)
- Howard S. Kim
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago IL
- Center for Health Services & Outcomes Research Northwestern University Feinberg School of Medicine Chicago IL
| | - D. Mark Courtney
- Department of Emergency Medicine University of Texas Southwestern Medical School Dallas TX
| | - Danielle M. McCarthy
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago IL
- Center for Health Services & Outcomes Research Northwestern University Feinberg School of Medicine Chicago IL
| | - David Cella
- Department of Medical Social Sciences Northwestern University Feinberg School of Medicine Chicago IL
- Center for Patient‐Centered Outcomes Northwestern University Feinberg School of Medicine Chicago IL
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Smith BC, Vigotsky AD, Apkarian AV, Schnitzer TJ. Temporal Factors Associated With Opioid Prescriptions for Patients With Pain Conditions in an Urban Emergency Department. JAMA Netw Open 2020; 3:e200802. [PMID: 32211867 PMCID: PMC7097712 DOI: 10.1001/jamanetworkopen.2020.0802] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
IMPORTANCE Opioid prescriptions for treatment of pain in emergency departments (EDs) are associated with long-term opioid use. The temporal pattern of opioid prescribing in the context of the opioid epidemic remains unknown. OBJECTIVE To examine the temporal pattern of opioid prescribing within an ED for varying pain conditions between 2009 and 2018. DESIGN, SETTING, AND PARTICIPANTS A population-based, cross-sectional study was conducted at the ED of an urban academic medical center. All patients treated within that ED between January 1, 2009, and December 31, 2018, were included. MAIN OUTCOMES AND MEASURES The proportion of patients prescribed an opioid for treatment of pain in the ED temporally by condition, condition type, patient demographics, and physician prescriber. RESULTS Between 2009 and 2018, 556 176 patient encounters took place in the ED, with 70 218 unique opioid prescriptions ordered. A total of 316 632 patients (55.9%) were female, 45 070 (42.6%) were of white race, and 43 412 (40.6%) were privately insured; the median age group was 41 to 45 years. Yearly opioid prescriptions decreased by 66.3% (from 16.3 to 5.5 opioids per 100 encounters) between 2013 and 2018, with a yearly adjusted odds ratio (aOR) of 0.808 (95% CI, 0.802-0.814) compared with the prior year. In patients with musculoskeletal pain (back, joint, limb, and neck pain), opioid prescribing decreased by 71.1% (from 36.7 to 10.6 opioids per 100 encounters between 2013 and 2018; aOR, 0.758; 95% CI, 0.744-0.773). In patients with musculoskeletal trauma (fracture, sprain, contusion, and injury), opioid prescribing decreased by 58.0% (from 34.2 to 14.8 opioids per 100 encounters; aOR, 0.811; 95% CI, 0.797-0.824). In patients with nonmusculoskeletal pain (abdominal pain, kidney stone, respiratory distress, and pharyngitis) opioid prescribing decreased by 53.7% (from 20.1 to 9.3 opioids per 100 encounters; aOR, 0.850; 95% CI, 0.834-0.868). Between 2009 and 2018, patients who were black (aOR, 0.760; 95% CI, 0.741-0.779) and those who were Asian (aOR, 0.714; 95% CI, 0.665-0.764) had the lowest odds of receiving an opioid compared with other racial/ethnic groups. CONCLUSIONS AND RELEVANCE There was a substantial temporal decrease in the number of opioid prescriptions within this ED during the study period. This decrease was associated with substantial relative reductions in opioid prescribing for treatment of musculoskeletal pain compared with fractures and kidney stones.
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Affiliation(s)
- Ben C. Smith
- Medical Student, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Andrew D. Vigotsky
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois
- Department of Statistics, Northwestern University, Evanston, Illinois
| | - A. Vania Apkarian
- Center for Translational Pain Research, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Thomas J. Schnitzer
- Anesthesiology and Medicine (Rheumatology), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Viglino D, Termoz Masson N, Verdetti A, Champel F, Falcon C, Mouthon A, Mabiala Makele P, Collomb Muret R, Maindet Dominici C, Maignan M. Multimodal oral analgesia for non-severe trauma patients: evaluation of a triage-nurse directed protocol combining methoxyflurane, paracetamol and oxycodone. Intern Emerg Med 2019; 14:1139-1145. [PMID: 31290084 DOI: 10.1007/s11739-019-02147-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 07/03/2019] [Indexed: 01/03/2023]
Abstract
Insufficient analgesia affects around 50% of emergency department patients. The use of a protocol helps to reduce the risk of oligoanalgesia in this context. Our objective was to describe the feasibility and efficacy of a multimodal analgesia protocol (combining paracetamol, oxycodone, and inhaled methoxyflurane) initiated by triage nurse. We performed a prospective, observational study in an emergency department (Grenoble Alpes University Hospital, France) between December 2017 and April 2018. Adult non-severe trauma patients with a numerical pain rating scale (NRS) score ≥ 4 were included. The primary efficacy criterion was the proportion of patients with an NRS score ≤ 3 at 15 min. Pain intensity was measured for 60 min and during radiography. Data on adverse events and satisfaction were recorded. A total of 200 adult patients were included (median [interquartile range (IQR)] age: 32 [23-49] years; 126 men (63%)). Sixty-six patients (33%) reported an NRS score ≤ 3 at 15 min. The time required to achieve a decrease of at least 2 points in the NRS score was 10 (5-20) min. The median [IQR] pain intensity was 4 [2-5] before radiography and 4 [2-6] during radiography. Adverse events were frequent (n = 128, 64%). No serious adverse events were reported. The patients and caregivers reported good levels of satisfaction. The administration of a nurse-driven multimodal analgesia protocol (combining paracetamol, oxycodone, and methoxyflurane) was feasible on admission to the emergency department. It rapidly produced long-lasting analgesia in adult trauma patients.Trial registration: NCT03380247.
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Affiliation(s)
- Damien Viglino
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Nicolas Termoz Masson
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Agnès Verdetti
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Flore Champel
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Cédric Falcon
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Alexis Mouthon
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Prudence Mabiala Makele
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Roselyne Collomb Muret
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | | | - Maxime Maignan
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France.
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Daoust R, Paquet J, Cournoyer A, Piette É, Morris J, Lessard J, Castonguay V, Williamson D, Chauny JM. Side effects from opioids used for acute pain after emergency department discharge. Am J Emerg Med 2019; 38:695-701. [PMID: 31182367 DOI: 10.1016/j.ajem.2019.06.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 05/31/2019] [Accepted: 06/01/2019] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE Opioid side effects are common when treating chronic pain. However, the frequency of opioid side effects has rarely been examined in acute pain conditions, particularly in a post emergency department (ED) setting. The objective of this study was to evaluate the short-term incidence of opioid-induced side effects (constipation, nausea/vomiting, dizziness, drowsiness, sweating, and weakness) in patients discharged from the ED with an opioid prescription. METHODS This is a prospective cohort study of patients aged ≥18 years who visited the ED for an acute pain condition (≤2 weeks) and were discharged with an opioid prescription. Patients completed a 14-day diary assessing daily pain medication use and side effects. RESULTS We recruited 386 patients with a median age of 54 years (IQR:43-66); 50% were women. During the 2-week follow-up, 80% of patients consumed opioids. Among the patients who used opioids, 79% (95%CI:75-83) reported side effects compared to 38% (95%CI:27-49) for non-users. Adjusting for age, sex, and pain condition, patients who used opioids were more likely to report constipation (OR:7.5; 95%CI:3.1-17.9), nausea/vomiting (OR:4.1; 95%CI:1.8-9.5), dizziness (OR:5.4; 95%CI: 2.2-13.2), drowsiness (OR:4.6; 95%CI:2.5-8.7), and weakness (OR:4.2; 95%CI:1.6-11.0) compared to non-users. A dose-response trend was observed for constipation but not for the other side effects. Nausea/vomiting (OR:2.0; 95%CI:1.1-3.6) and dizziness (OR:1.9; 95%CI:1.1-3.4) were more often associated with oxycodone than with morphine. CONCLUSION As observed for chronic pain treatment, side effects are highly prevalent during short-term opioid treatment for acute pain. Physicians should inform patients about those side effects and should consider prescribing laxatives.
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Affiliation(s)
- Raoul Daoust
- Department of Emergency Medicine, Research Centre, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada; Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada.
| | - Jean Paquet
- Department of Emergency Medicine, Research Centre, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
| | - Alexis Cournoyer
- Department of Emergency Medicine, Research Centre, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada; Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
| | - Éric Piette
- Department of Emergency Medicine, Research Centre, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada; Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
| | - Judy Morris
- Department of Emergency Medicine, Research Centre, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada; Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
| | - Justine Lessard
- Department of Emergency Medicine, Research Centre, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada; Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
| | - Véronique Castonguay
- Department of Emergency Medicine, Research Centre, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada; Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
| | - David Williamson
- Research Centre, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada; Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada
| | - Jean-Marc Chauny
- Department of Emergency Medicine, Research Centre, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada; Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
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Abstract
PURPOSE We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. METHODS A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation. The guideline was submitted to the Orthopaedic Trauma Association (OTA) for review and was approved on October 16, 2018. RESULTS We present evidence-based best practice recommendations and pain medication recommendations with the hope that they can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. Recommendations are presented regarding pain management, cognitive strategies, physical strategies, strategies for patients on long term opioids at presentation, and system implementation strategies. We recommend the use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia. We also recommend connecting patients to psychosocial interventions as indicated and considering anxiety reduction strategies such as aromatherapy. Finally, we also recommend physical strategies including ice, elevation, and transcutaneous electrical stimulation. Prescribing for patients on long term opioids at presentation should be limited to one prescriber. Both pain and sedation should be assessed regularly for inpatients with short, validated tools. Finally, the group supports querying the relevant regional and state prescription drug monitoring program, development of clinical decision support, opioid education efforts for prescribers and patients, and implementing a department or organization pain medication prescribing strategy or policy. CONCLUSIONS Balancing comfort and patient safety following acute musculoskeletal injury is possible when utilizing a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this guideline, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.
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Miller AC, Khan AM, Castro Bigalli AA, Sewell KA, King AR, Ghadermarzi S, Mao Y, Zehtabchi S. Neuroleptanalgesia for acute abdominal pain: a systematic review. J Pain Res 2019; 12:787-801. [PMID: 30881092 PMCID: PMC6396833 DOI: 10.2147/jpr.s187798] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Acute abdominal pain (AAP) comprises up to 10% of all emergency department (ED) visits. Current pain management practice is moving toward multi-modal analgesia regimens that decrease opioid use. OBJECTIVE This project sought to determine whether, in patients with AAP (population), does administration of butyrophenone antipsychotics (intervention) compared to placebo, usual care, or opiates alone (comparisons) improve analgesia or decrease opiate consumption (outcomes)? METHODS A structured search was performed in Cochrane CENTRAL, CINAHL, Database of Abstracts of Reviews of Effects, Directory of Open Access Journals, Embase, IEEE-Xplorer, Latin American and Caribbean Health Sciences Literature, Magiran, PubMed, Scientific Information Database, Scopus, TÜBİTAK ULAKBİM, and Web of Science. Clinical trial registries (ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and Australian New Zealand Clinical Trials Registry), relevant bibliographies, and conference proceedings were also searched. Searches were not limited by date, language, or publication status. Studies eligible for inclusion were prospective randomized clinical trials enrolling patients (age ≥18 years) with AAP treated in acute care environments (ED, intensive care unit, postoperative). The butyrophenone must have been administered either intravenously or intra-muscularly. Comparison groups included placebo, opiate only, corticosteroids, non-steroidal anti-inflammatory drugs, or acetaminophen. RESULTS We identified 7,217 references. Six studies met inclusion criteria. One study assessed ED patients with AAP associated with gastroparesis, whereas five studies assessed patients with postoperative AAP: abdominal hysterectomy (n=4), sleeve gastrectomy (n=1). Three of four studies found improvements in pain intensity with butyrophenone use. Three of five studies reported no change in postoperative opiate consumption, while two reported a decrease. One ED study reported no change in patient satisfaction, while one postoperative study reported improved satisfaction scores. Both extrapyramidal side effects (n=3) and sedation (n=3) were reported as unchanged. CONCLUSION Based on available evidence, we cannot draw a conclusion on the efficacy or benefit of neuroleptanalgesia in the management of patients with AAP. However, preliminary data suggest that it may improve analgesia and decrease opiate consumption.
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Affiliation(s)
- Andrew C Miller
- Department of Emergency Medicine, Vidant Medical Center, Brody School of Medicine, East Carolina University, Greenville, NC, USA,
- The MORZAK Collaborative, Orlando, FL, USA,
| | | | | | - Kerry A Sewell
- William E. Laupus Health Sciences Library, East Carolina University, Greenville, NC, USA
| | - Alexandra R King
- Division of Emergency Medicine and Toxicology, Department of Pharmacy, Vidant Medical Center, Greenville, NC, USA
| | - Shadi Ghadermarzi
- Department of Internal Medicine, Vidant Medical Center, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Yuxuan Mao
- Department of Internal Medicine, Vidant Medical Center, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Shahriar Zehtabchi
- Department of Emergency Medicine, State University of New York Downstate Medical Center, Brooklyn, NY, USA
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Effect of a Combination of Intranasal Ketorolac and Nitrous Oxide on the Success of the Inferior Alveolar Nerve Block in Patients with Symptomatic Irreversible Pulpitis: A Prospective, Randomized, Double-blind Study. J Endod 2018; 44:9-13. [DOI: 10.1016/j.joen.2017.09.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 09/15/2017] [Accepted: 09/22/2017] [Indexed: 11/21/2022]
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13
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Opioid-sparing Effects of SoluMatrix Indomethacin in a Phase 3 Study in Patients With Acute Postoperative Pain. Clin J Pain 2017; 34:138-144. [PMID: 28591082 DOI: 10.1097/ajp.0000000000000525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To report the opioid-sparing effects of SoluMatrix indomethacin, developed using SoluMatrix Fine Particle Technology, in a phase 3 study in patients with acute pain following bunionectomy. METHODS This phase 3, placebo-controlled study randomized 462 patients with moderate-to-severe pain following bunionectomy surgery to receive SoluMatrix indomethacin 40 mg 3 times daily, SoluMatrix indomethacin 40 mg twice daily, SoluMatrix indomethacin 20 mg 3 times daily, celecoxib 400-mg loading dose followed by 200 mg twice daily, or placebo. Patients were permitted to receive opioid-containing rescue medication throughout the study. The proportion of patients who used rescue medication and the amount of rescue medication used on the first (0 to 24 h) and second (>24 to 48 h) days following initial dose of study medication, as well as time to first rescue medication use, were assessed. RESULTS Significantly fewer patients who received SoluMatrix indomethacin 40 or 20 mg 3 times daily used opioid-containing rescue medication on day 1 compared with those receiving placebo (P≤0.034), and fewer patients in all active treatment groups used rescue medication during the second day compared with those in the placebo group (P<0.001). All active treatment groups used significantly fewer rescue medication tablets on days 1 and 2 following randomization compared with placebo (P<0.001). The most common adverse events were nausea, postprocedural edema, and headache. DISCUSSION SoluMatrix indomethacin was associated with opioid-sparing effects in patients with acute postoperative pain.
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Imamoglu M, Aygun A, Bekar O, Erdem E, Cicek M, Tatli O, Karaca Y, Sahin A, Turkmen S, Turedi S. A retrospective analysis of nebulized versus intravenous fentanyl for renal colic. Am J Emerg Med 2017; 35:757-763. [PMID: 28119014 DOI: 10.1016/j.ajem.2017.01.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 01/13/2017] [Accepted: 01/14/2017] [Indexed: 11/16/2022] Open
Abstract
STUDY OBJECTIVE To assess the effectiveness of nebulized fentanyl used for analgesia in renal colic. MATERIALS/METHODS This research was planned as a randomized, blinded study in which prospectively collected data were analyzed retrospectively to compare nebulized and intravenous (iv) fentanyl therapies. Patients with renal colic with 'moderate' or worse pain on a four-point verbal pain score (VPS) or with pain of 20mm or above on a 100-mm visual analogue score (VAS) at time of presentation were randomized into iv fentanyl (n=62) or nebulized fentanyl (n=53) study groups. Decreases in VAS and VPS scores at 15 and 30min compared to baseline, rescue analgesia requirements and side-effects between the groups were compared. RESULTS Both iv fentanyl and nebulized fentanyl provided effective analgesia in renal colic patients at the end of 30min. However, iv fentanyl provided more rapid and more effective analgesia than nebulized fentanyl. Patients receiving iv fentanyl had lower rescue analgesia requirements than those receiving nebulized fentanyl (37.1% vs 54.7%), although the difference was not statistically significant (p=0.058). In addition, side-effects were more common in the iv fentanyl group compared to the nebulized fentanyl group (22.1% vs 9.4%), although the difference was also not significant (p=0.058). CONCLUSION Nebulized fentanyl provides effective analgesia in patients with renal colic. However, iv fentanyl exhibits more rapid and more powerful analgesic effects than nebulized fentanyl. Nonetheless, due to its ease of use and few potential risks and side-effects the nebulized form can be used as an alternative in renal colic.
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Affiliation(s)
- Melih Imamoglu
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Ali Aygun
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Omer Bekar
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Erkan Erdem
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Mustafa Cicek
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Ozgur Tatli
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Yunus Karaca
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Aynur Sahin
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Suha Turkmen
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Suleyman Turedi
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey.
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Strayer RJ, Motov SM, Nelson LS. Something for pain: Responsible opioid use in emergency medicine. Am J Emerg Med 2016; 35:337-341. [PMID: 27802876 DOI: 10.1016/j.ajem.2016.10.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 10/18/2016] [Accepted: 10/20/2016] [Indexed: 10/20/2022] Open
Abstract
The United States is currently experiencing a public health crisis of opioid addiction, which has its genesis in an industry marketing effort that successfully encouraged clinicians to prescribe opioids liberally, and asserted the safety of prescribing opioids for chronic non-cancer pain, despite a preponderance of evidence demonstrating the risks of dependence and misuse. The resulting rise in opioid use has pushed drug overdose deaths in front of motor vehicle collisions to become the leading cause of accidental death in the country. Emergency providers frequently treat patients for complications of opioid abuse, and also manage patients with acute and chronic pain, for which opioids are routinely prescribed. Emergency providers are therefore well positioned to both prevent new cases of opioid misuse and initiate appropriate treatment of existing opioid addicts. In opioid-naive patients, this is accomplished by a careful consideration of the likelihood of benefit and harm of an opioid prescription for acute pain. If opioids are prescribed, the chance of harm is reduced by matching the number of pills prescribed to the expected duration of pain and selecting an opioid preparation with low abuse liability. Patients who present to acute care with exacerbations of chronic pain or painful conditions associated with opioid misuse are best managed by treating symptoms with opioid alternatives and encouraging treatment for opioid addiction.
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Affiliation(s)
- Reuben J Strayer
- 79-01 Broadway, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Elmhurst, NY 11373, United States.
| | - Sergey M Motov
- 4802 Tenth Ave, Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY 11219, United States
| | - Lewis S Nelson
- 185 South Orange Avenue, Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, United States
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