A review of transbuccal fentanyl use in the emergency department

Commonly used agent for acute pain management of sickle cell anemia in Saudi Emergency Department: A narrative review

INTRODUCTION

Sickle-cell disease (SCD) is one of the most common hematologic inherited disorders in Saudi Arabia. Vaso-occlusive pain crisis in SCD is a major cause for emergency visits and patients' pain may be undertreated. This study presents a narrative literature review of current agents used to manage acute pain crisis in SCD patients presenting to the emergency department in hospitals of Saudi Arabia.

METHOD

We conducted a narrative review on relevant published articles about sickle cell disease pain crisis management in Saudi Arabia and included seven relevant studies based on our inclusion criteria.

RESULTS

Using our search strategy, we included 7 studies Out of 4052. Studies included were conducted in different locations in the country. Four studies were in the Eastern region while only one in Western and One in Central regions. Those studies included around 2441 patients, in total. Morphine was used in 5 studies out of the 7 included. Pethidine was used in 4. One study used Isoxsuprine and another study used tinzaparin.

CONCLUSION

We found that continuous administration of IV morphine accompanied by oral analgesics including NSAIDs and acetaminophen is the most commonly used practice for treating SCD patients presenting with a vaso-occlusive pain crisis. Possible effectiveness of tinzaparin, isoxsuprine, and pethidine as therapeutic options may be considered. However, there was no recommendation for a certain agent to be prescribed. We recommend conducting further clinical randomized-controlled trials.

Fentanyl buccal tablet versus oral oxycodone for Emergency Department treatment of musculoskeletal pain

Background: Emergency Department (ED) analgesia can potentially be delivered quickly using transbuccal administration. A previous study identified time-of-onset advantage of a 100 mcg fentanyl buccal tablet (FBT) as compared to a dose of 5 mg oxycodone with 325 mg acetaminophen. The current study reports comparison of higher-dose (200 mcg) FBT as compared to a more commonly used oxycodone dose of 10 mg with 650 mg acetaminophen. Methods: Time frame: Patients were enrolled between October 2012 and October 2014.

Setting: The study was conducted in an urban teaching ED with annual census of 55,000.

Patients: The 50 convenience-sampled cases met eligibility criteria of age 18-60, with isolated orthopedic complaints; subjects required X-ray to rule-out fracture, and to have pain sufficient to warrant opioids.

Interventions: In this double-blind placebo-controlled analgesia trial, patients were randomized to one of two study groups. OXY subjects received two orally ingested tablets, each containing 5 mg oxycodone and 325 mg acetaminophen, and a transbuccal inactive comparator. FBT subjects received two placebo oral tablets and a 200 mcg FBT.

Data: The main study endpoint was achievement of at least two points' reduction in numeric pain rating scale (NPRS) within ten minutes of study drug administration. NPRS was assessed at the time of study entry and every five minutes' post-drug administration for an hour. Secondary endpoints included assessment of side effects and subjects' desire to have the same medication for future similar pain.

Analysis: Categorical data were assessed with binomial exact 95% confidence intervals (CIs). Continuous data, after being demonstrated as non-normal with skewness-kurtosis testing, were analyzed with Kruskal-Wallis testing. Multivariate Cox proportional hazards analysis was performed to assess whether, after adjustment for potential confounders, there was a difference between FBT and OXY groups with respect to time to achieving significant analgesia. Results: Study groups were similar with respect to age (medians: OXY 34, FBT 38, p = 0.47), initial pain score (median 8 in each group), sex (proportion of males: OXY 64%, FBT 48%, p = 0.25), and ethnicity (proportion of whites: OXY 68%, FBT 56%, p = 0.38). The same proportion (52%) of OXY and FBT cases achieved significant reduction in pain within 15 minutes. Multivariate Cox regression adjusting for potential confounders confirmed (p = 0.28) no difference in rates of pain reduction between OXY and FBT. There were no major complications in either group. The majority of subjects in each group (80% in FBT group versus 76% in OXY group, p = 0.73) expressed high satisfaction and preference to receive the same regimen in future. Conclusion: This study's results suggest approximate equivalence between 200 mcg FBT and 10 mg oxycodone with 650 mg acetaminophen, with respect to time-to-analgesia, analgesic efficacy, side effects, and patient satisfaction.

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.