Introduction

    visit the emergency department (ED)

  • 2. It is estimated that at least 30,000 people die in the United States as a direct result of the use of opioids each year
  • 3. Although it seems that no specific specialty has been primarily responsible for the opioid epidemic, clinicians in the ED are uniquely positioned on the front lines to be able to combat the ongoing crisis
  • 4. An expanding body of research is beginning to emerge that suggests that nonopioid medications such as acetaminophen or nonsteroidal anti-inflammatories

Pharmacology

Non-Opioid AgentsDrug Info
AcetaminophenDose: 325-1000 mg PO/Rectal/IV*
Onset: PO 10-30 min; IV ~5 min
Duration: PO ~4.5 hr; IV ~3 hr
Indication: mild to moderate pain
IbuprofenDose: 400-800 mg PO
Onset: 15-30 min
Duration: ~6hrs
Indication: mild to moderate pain
KetorolacDose: PO: 10 mg; IV/IM: 15-30 mg
Onset: ~30 min
Duration: 4-6 hours
Indication: acute flank, abdominal, MSK, headache, fractures
Ketamine*Dose: 0.15-0.30 mg/kg ± 0.15-0.25 mg/kg/hr infusion IV/IM/IN
Onset: 10-30 min
Duration: 30-60 min
Indication: Moderate to severe MSK pain, flank pain
Lidocaine*Dose: 1.5 mg/kg IV; 5% Patch 12hr out of 24hr IV/transdermal
Onset: IV 1-5 min; Patch ~4 hr
Duration: IV 0.5-1 hr; Patch ~12 hr
Indication: Renal Colic, mild MSK pain
Metoclopramide/prochlorperazine + diphenhydramineDose: 10 mg + 25-50 mg Benadryl IV/PO
Onset: 5-10 min
Duration: 3-5 hr
Indication: Migraine

* Limited access or nonformulary at some institutions.

Evidence

Author, YearDesign/Sample Size/Type of PainNonopioid InterventionComparatorOutcome
Chang, 2017RCT
n=411
Moderate to severe acute extremity pain		Ibuprofen 400 mg + APAP 1000 mgOxycodone/APAP 5/325mg
Hydrocodone/APAP 5/325
Codeine/APAP 30/300 mg		Reduction in pain score 2 hours after single dose
Ibuprofen 400 mg + APAP 1000 mg = 4.3
Oxycodone/APAP 5/325mg = 4.4
Hydrocodone/APAP 5/325 = 3.5
Codeine/APAP 30/300 mg = 3.9
"..no statistically significant or clinically important differences in pain reduction"
Rainer, 2000RCT
N=148
Painful isolated limb injuries		IV Ketorolac 10mg x 1 + PRN IV ketorolac 5mg q5m (max 30 mg)Morphine 5mg x 1 + PRN morphine 2.5 mg q5m (max 15 mg)No difference in median time to pain relief
Patients' satisfaction was 6.0 for ketorolac and 5.0 for morphine (P<0.0001)
Median reduction in pain score in the was 1.09/hr vs 0.87/hr in the ketorolac and morphine group respectively (P=0.003)
Motov, 2018RCT
n=60 (30/arm)
Severe acute abdominal, flank, MSK, or malignant pain		IV Ketamine 0.3 mg/kg over 15 minMorphine 0.1 mg/kg over 15 minPrimary change in mean pain scores was not significantly different
Higher rates of psychoperceptual adverse effects with ketamine
No statistically significant differences with respect to changes in vital signs and need for rescue medication
Soleimanpour, 2012RCT
n=240
Renal colic		IV lidocaine (1.5 mg/kg)IV morphine (0.1 mg/kg)Pain score at 5 min: lidocaine 3.18 vs morphine 4.45 (p=0.001)
Pain score at 30 min: lidocaine 1.13 vs morphine 2.23 (p=0.001)
Lidocaine 90% vs 70% morphine responded appropriately (score<3) at end of treatment (p=0.0001)
Kostic, 2010RCT
n=66
Acute migraine		IV prochlorperazine 10 mg + IV diphenhydramine 12.5 mgSubQ sumatriptan 6 mg + placeboBaseline pain scores were similar for the groups (76 versus 71 mm)
Mean reductions in pain intensity at 80 minutes or time of ED discharge were 73 mm vs 50 mm
Sedation, nausea, and headache recurrence rates were similar

Conclusions

References

  • Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved September 6, 2018, from http://www.micromedexsolutions.com/
  • Motov S. The Treatment of Acute Pain in the Emergency Department: A White Paper Position Statement Prepared for the American Academy of Emergency Medicine. J Emerg Med. 2018 May;54(5):731-736.
  • Chang AK. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial. JAMA. 2017 Nov 7;318(17):1661-1667
  • Rainer TH. Cost effectiveness analysis of intravenous ketorolac and morphine for treating pain after limb injury: double blind randomised controlled trial. BMJ. 2000 Nov 18;321(7271):1247-51.
  • Motov S. Intravenous subdissociative-dose ketamine versus morphine for acute geriatric pain in the Emergency Department: A randomized controlled trial. Am J Emerg Med. 2018 May 16. pii: S0735-6757(18)30407-8.
  • Soleimanpour H. Effectiveness of intravenous lidocaine versus intravenous morphine for patients with renal colic in the emergency department. BMC Urol. 2012 May 4;12:13. doi: 10.1186/1471-2490-12-13.
  • Kostic MA. A prospective, randomized trial of intravenous prochlorperazine versus subcutaneous sumatriptan in acute migraine therapy in the emergency department. Ann Emerg Med. 2010 Jul;56(1):1-6.
Tags: acetaminophen ibuprofen NSAIDs opioids