Adjunct Analgesic Use for Acute Pain in the Emergency Department

Abstract

Purpose:Multimodal analgesia is common practice in the postoperative setting, but the utility of adjunctive analgesia in the emergency department (ED) is less understood. The primary objective of this study was to analyze ED prescriber ordering habits for adjunct nonopioid pain medication for opioid-naïve patients who require intravenous (IV) morphine or hydromorphone for acute pain. Secondary objectives were to assess initial and total opioid consumption in morphine equivalent units (MEU), pain scores, and ED length of stay (LOS) between groups. Methods: A retrospective chart review of adult patients who presented to the ED at a large academic medical center and received IV morphine or hydromorphone for acute pain was conducted. Patients were analyzed according to initial opioid received and presence or absence of adjunct nonopioid analgesics. Results: A total of 102 patient charts were analyzed. Adjunctive nonopioid analgesics were ordered on 38% of patients. Patients who received an adjunct nonopioid analgesic received a smaller mean initial opioid dose than those who did not (4.73 vs 5.48 MEU, p = .08). Initial pain score reduction on the 11-point Numeric Rating Scale (NRS) did not differ between patients who received adjunct analgesics versus those who did not (3 vs 4, p = .75). Patients who received adjunct analgesics were associated with a decreased ED LOS (294 vs 342 minutes, p = .04). Conclusion: A small proportion of patients with acute pain received a nonopioid analgesic in conjunction to IV opioids. Further studies are warranted to assess the impact of adjunct analgesics for patients with acute pain.

Randomized Clinical Trial of Intravenous Acetaminophen as an Analgesic Adjunct for Older Adults With Acute Severe Pain

“…IV acetaminophen is infrequently used in the ED. 27 In the 2015 National Hospital Ambulatory Medical Care Survey it was only prescribed in 5 out of 21,000 visits. Hence, its role in the care of ED patients is relatively unknown.…”

Alternative Viewpoint: Predictors of Response in Emergency Department Patients Receiving Intravenous Opioids for Severe Pain

“…Finally, it appears that 35% of patients in this study received hydromorphone as their initial analgesic. It has been shown that patients receive a larger number of morphine equivalent units when hydromorphone is administered compared to morphine . While it was found that larger milligram doses negatively influenced opioid response, the authors did not differentiate between patients receiving morphine versus hydromorphone.…”

“…Second, reductions in pain scores are not the only measure of response to opioids. In a previous study, patients in both groups received similar total doses of opioids; however, patients who received adjunctive analgesics in addition to an opioid had a 48‐minute reduction in their emergency department (ED) treatment time, suggesting that the use of a multimodal regimen leads to faster disposition times and shorter ED length of stay.…”

“…It has been shown that patients receive a larger number of morphine equivalent units when hydromorphone is administered compared to morphine. 5,7 While it was found that larger milligram doses negatively influenced opioid response, the authors did not differentiate between patients receiving morphine versus hydromorphone. It is conceivable that hydromorphone was chosen in patients with higher pain scores or a specific pain location.…”

“…It appears that only 3% of patients in this study received adjunctive medications, much less than previously reported. 5,6 Utilization of other modalities with different analgesic mechanisms provides multiple avenues for pain to be controlled and thus could augment the opioid response.…”