Original Contribution Acupuncture vs intravenous morphine in the management of acute pain in the ED ☆,☆☆,★,★★ Mohamed Habib Grissa, MD a , Houda Baccouche, MD a , Hamdi Boubaker, MD a , Kaouthar Beltaief, MD a , Nasri Bzeouich, MD a , Nizar Fredj, MD a , Mohamed Amine Msolli, MD a , Riadh Boukef, MD b , Wahid Bouida, MD a , Semir Nouira, MD a, ⁎ a Emergency Department, Fattouma Bourguiba University Hospital Monastir, Tunisia and Research Laboratory (LR12SP18) University of Monastir, Tunisia b Emergency Department, Sahloul University Hospital, Sousse, Tunisia and Research Laboratory (LR12SP18) University of Monastir, Tunisia abstract article info Article history: Received 16 May 2016 Received in revised form 16 July 2016 Accepted 17 July 2016 Available online xxxx Background: Acupuncture is one of the oldest techniques to treat pain and is commonly used for a large number of indications. However, there is no sufficient evidence to support its application in acute medical settings. Methods: This was a prospective, randomized trial of acupuncture vs morphine to treat ED patients with acute onset moderate to severe pain. Primary outcome consists of the degree of pain relief with significant pain reduction defined as a pain score re- duction ≥50% of its initial value. We also analyzed the pain reduction time and the occurrence of short-term ad- verse effects. We included in the protocol 300 patients with acute pain: 150 in each group. Results: Success rate was significantly different between the 2 groups (92% in the acupuncture group vs 78% in the morphine group P b .001). Resolution time was 16 ± 8 minutes in the acupuncture group vs 28 ± 14 minutes in the morphine group (P b .005). Overall, 89 patients (29.6%) experienced minor adverse effects: 85 (56.6%) in morphine group and 4 (2.6%) in acupuncture group (P b .001). No major adverse effects were recorded during the study protocol. In patients with acute pain presenting to the ED, acupuncture was associated with more ef- fective and faster analgesia with better tolerance. Conclusion: This article provides an update on one of the oldest pain relief techniques (acupuncture) that could find a central place in the management of acute care settings. This should be considered especially in today's in- creasingly complicated and polymedicated patients to avoid adverse drug reactions. © 2016 Elsevier Inc. All rights reserved. 1. Introduction Pain is a common cause of ED visits and its control remains a chal- lenge and health priority worldwide. Many techniques were developed to control pain and to ensure patients comfort but their application is still difficult especially in ED settings, due to the variety of treated con- ditions, the nonavailability of qualified practitioners, and the patients' specifications [1]. Pharmacologic methods, in particular intravenous (IV) opioids, are the most used analgesic agents with regard to their rapid action and high efficacy, but the use of these drugs can be limited by their adverse effects [2]. Nonpharmacologic pain relief techniques such as acupuncture have been proposed. During the second half of the twentieth century, acupuncture was established in Europe and in the last 2 decades, and it has spread around the world [3]. In Tunisia, acupuncture was introduced into the health system in the 90s, particu- larly to treat pain. The World Health Organization has recognized acupuncture as a safe and effective therapy for a myriad of conditions causing pain and dis- comfort [4]. However, the introduction of acupuncture in the treatment of pain in the ED is rare. Acupuncture was shown to be as effective as morphine and it has a better safety profile which makes it a suitable method of pain control in certain circumstances such as headaches, mi- graines, back pain, cervical pain, and osteoarthritis [5]. In a recent systematic review, it has been concluded that there is in- sufficient evidence for the use of acupuncture in the ED settings because American Journal of Emergency Medicine xxx (2016) xxx–xxx ☆ Study registration: The protocol was registered at clinicaltrials.gov under: NCT02460913. ☆☆ Funding: The authors declare that no funding sources were provided. ★ Conflict of interest: The authors declare that they have no conflict of interest. ★★ Author contributions: HB and SN conceived the study, and designed the trial. SN, HB, WB, RB, MHG, HB, and KB supervised the conduct of the trial and data collection. HB was the acupuncturist of the study. HB, NB, NF, and MAM undertook recruitment of patients and managed the data, including quality control. SN, HB, NB, and MHG performed statisti- cal analysis and analyzed the data. SN drafted the manuscript. HB and NB revised the man- uscript. SN takes the responsibility for the paper as a whole. This study was supported in part by the Tunisian Ministry of Scientific Research. ⁎ Corresponding author at: Emergency Department, Fattouma Bourguiba University Hospital Monastir, 5000, Tunisia, Research Laboratory (LR12SP18) University of Monastir, Tunisia. Tel.: +216 73 106 046; fax: +216 73 460 678. E-mail address: Semir.nouira@rns.tn (S. Nouira). http://dx.doi.org/10.1016/j.ajem.2016.07.028 0735-6757/© 2016 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem Please cite this article as: Grissa MH, et al, Acupuncture vs intravenous morphine in the management of acute pain in the ED, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.07.028