Volume 4 • Issue 1 • 1000171 Emergency Med ISSN: 2165-7548 EGM, an open access journal Nalamachu et al., Emergency Med 2013, 4:1 DOI: 10.4172/2165-7548.1000171 Review Article Open Access Emergency Medicine: Open Access Acute Pain Management in the Emergency Department: Emphasis on NSAIDs Srinivas Nalamachu 1 , Joseph V Pergolizzi 2 , Robert B Raffa 3 and Robert Taylor 4 * 1 International Clinical Research Institute, Overland Park, KS, USA 2 Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA 2 Department of Anesthesiology, Georgetown University School of Medicine, Washington, DC, USA 2 Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, USA 3 Department of Pharmaceutical Sciences, Temple University School of Pharmacy, Philadelphia, PA, USA 4 NEMA Research Inc., Naples, FL, USA *Corresponding author: Robert Taylor, NEMA Research Inc., Naples, FL 34108, USA, Tel: 239-597-3662; Fax: 239-597-7566; E-mail: Robert.taylor.phd@gmail.com Received November 25, 2013; Accepted December 28, 2013; Published December 31, 2013 Citation: Nalamachu S, Pergolizzi JV, Raffa RB, Taylor R (2013) Acute Pain Management in the Emergency Department: Emphasis on NSAIDs. Emergency Med 4: 171. doi:10.4172/2165-7548.1000171 Copyright: © 2013 Nalamachu S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Keywords: Emergency department; Body mass index; Oligoanalgesia Introduction In the United States, there were over 129 million Emergency Department (ED) visits in 2010, [1] with acute pain syndromes, including stomach pain, chest pain, musculoskeletal pain, headache, and earache, among the leading complaints [2]. Emergency care focuses on immediate, short-term (acute) analgesia in a hectic setting with little opportunity for follow-up. Te pharmacological treatment of acute pain involves balancing its potential benefts against potential harms, but much of what is known about analgesic safety and efcacy has been derived from studies of mid- and longer-term use [3,4]. Tere are few guidelines that address pain management in the ED setting, although guidelines for specifc conditions and populations exist [5-7]. In 1999, the Joint Commission on Accreditation of Healthcare Organizations declared pain as the “ffh vital sign” and required hospitals to make pain control a priority [8]. For reasons unique to the ED setting, pain is not as well managed in the ED as in the surgical setting [9]. About half of ED patients complaining of pain receive no analgesic, and of patients reporting severe pain, 63% receive no analgesic [10]. In a survey of 842 patients at 20 U.S. and Canadian hospitals, only 60% of ED patients received analgesics with a median delay of 90 minutes (range 0 to 962 minutes) and, most concerning, 74% were discharged in moderate to severe pain [11]. Tere are multiple barriers to adequate pain control in the ED. One is that patients may not request analgesia. In a survey, it was found that 42% of ED patients discharged without analgesics had wanted them, but 31% of that group did not specifcally request them [11]. New emphasis on patient satisfaction may drive a change here, in that efective pain control signifcantly improved patient satisfaction scores of ED care (n=328) [12]. So while patients may not always ask for pain relievers, they may want or expect them. Emergency clinicians practice in a unique atmosphere that emphasizes triage and ofen relies on the rapid transfer of patients to other clinical departments for more specialized care. Te nuances of pain management can be lost in an environment Abstract Millions of patients are treated every year for acute pain symptoms in the Emergency Department (ED), but pain control in this setting still remains suboptimal. This may be due to the logistical challenges in the ED, ED clinicians’ limited education and training in pain control, regulatory and legal concerns, and other barriers to prescribing. The most common analgesics used in the ED are acetaminophen (paracetamol), Non Steroidal Anti-Infammatory Drugs (NSAIDs), and opioids. All are effective in relieving pain, but are also associated with serious side effects. Thus, pain control in the ED becomes a balancing act of weighing potential benefts and risks. NSAIDs are often the appropriate choice for many of the common acute pain conditions encountered in the ED, but because of risks associated, administration is often limited. A review of the literature regarding current ED pain treatment practices and guidelines, patient and clinician barriers to pain treatment in the ED, and the pros and cons of current analgesic options for the ED is warranted and timely. The objectives of the current review are to: (1) provide healthcare providers with an overview of the current state of acute pain treatment in the emergency room setting, (2) describe the common drug treatments utilized in emergency medicine, (3) review advantages and disadvantages of these treatments, with a focus on NSAIDs, and (4) examine the potential value of novel “low dose” NSAID formulations for use in this setting. that emphasizes rapid and transient care. Another barrier is clinicians’ generally inadequate training in acute pain management, reticence to use opioids, the “ED culture,” as well as personal biases [13]. Moreover, many clinicians in and outside the ED are rightly concerned about potential adverse efects of analgesics and may hesitate to prescribe potentially harmful drugs to patients they are not going to follow. Such non-clinical factors have been shown to infuence prescribing decisions. For example, in a study of opioid prescribing practices at a single center before and afer the arrest of a physician for drug diversion, patients with moderate pain were signifcantly less likely to be prescribed an opioid immediately (<90 days) afer the arrest than before (0.4 likelihood ratio, confdence interval, 0.2 to 0.7), although prescribing patterns for patients in mild and severe pain remained unchanged [14]. In New York state, I-STOP legislation passed in 2012 requires all prescribers of Schedule II, III, and IV controlled substances to consult the Prescription Monitoring Program in that state prior to prescribing drugs [15]. Since emergency medicine ranks third among all specialties for writing opioid prescriptions for 10-19 year olds and 20-29 years old and ranks fourth for 30-39 year olds, [16] emergency medicine serves a population at high risk for inappropriate opioid usen [17]. Tis may increasingly cause emergency room clinicians to hesitate to prescribe opiates. So common is misuse of opioids in the emergency setting that the term “oligoanalgesia” has been used to describe the situation [18]. E m e r g e n c y M e d i c i n e : O p e n A c c e s s ISSN: 2165-7548