Effectiveness of Transnasal Butorphanol for the Treatment of Musculoskeletal Pain JAMES L. SCOTT, MD, MARKS. SMITH, MD, SANDRA M. SANFORD, RN, MSN, ROBERT F. SHESSER, MD, ROBERT E. ROSENTHAL, MD, JEFFREY P. SMITH, MD, A prospective, open-label study of the effectiveness of transnasal butor- phanol in the treatment of pain resulting from muscuioskeletai injuries. Twenty-eight patients with strains (n = 20), fractures (n = 6), contusions (n = l), and stab wounds (n = 1) were included. All patients were examined by an attending level emergency medicine physician and deemed to have pain severe enough to warrant parenteral narcotic anai- gesia. Ail patients received an initial l-mg dose of transnasal butorpha- noi. Subsequent dosing was flexible depending on response to the initial dose. Ail patients received pain relief from transnasal butorphanol, and only one requested alternative analgesic medication. Fifty-seven percent (n = 16) of patients noticed at least a little relief of pain within 6 minutes of administration end 93% (n = 26) received at least a little relief within 15 minutes. Seventy-one percent of the patients received a 50% reduction of pain within 60 minutes. No serious side effects were noted, but drows- iness occurred in 62% (n = 23) and dininess in 54% (n = 16) of the patlents. One patient discontinued participation in the study because of nausea. In this limited trial transnasal butorphanol proved to be a rapidly effective opioid analgesic. Further controlled studies comparing transna- sal butorphanol with standard parenterai narcotics are needed. (Am J Emerg Med 1994;12:469-471. Copyright 0 1994 by W.B. Saunders Com- pany.) The management of acute pain in the emergency depart- ment (ED) has been the subject of much discussion in the literature and is undoubtedly one of the most important as- pects of emergency care. ‘*’ The ability to relieve acute pain in the ED and to provide continued relief after discharge is one of the most important functions of the emergency phy- sician. In the ED, parenteral opioid analgesics and newer non-narcotic analgesics such as ketorolac allow the emer- gency physician to control pain rapidly and effectively. Most patients can be discharged from the ED with oral analgesics to provide continued pain relief. However, some patients’ pain is too severe for treatment with oral analgesics and requires continued parenteral analgesic administration. A second problem is pain that is episodic and prohibits the From the Department of Emergency Medicine, The Ronald Reagan institute of Emergency Medicine, The George Washing- ton University Medical Center, Washington, DC. Manuscript received December 29, 1993; revision accepted March 4, 1994. Supported in part by Bristol-Myers Squibb. Address reprint requests to Dr James L. Scott, Department of Emergency Medicine, The George Washington University Med- ical Center, 2140 Pennsylvania Ave, NW, Washington, DC 20037. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Key Wor ds: Analgesia, butorphanol, pain, transnasal. Copyright 0 1994 W.B. Saunders Company. 0735-6757/9411204-0020$5.00/O CRAIG F. FEIED, MD, KEITH T. GHEZZI, MD, D. MICHAEL HUNT, MD development of steady-state levels of pain medication. A good example is renal colic, in which the pain may be so severe that oral analgesics will not control it, or the pain may resolve only to recur later when no analgesics remain in circulation. This pilot study was undertaken to examine the effective- ness and safety of a known opioid analgesic (butorphanol) when delivered through a new transnasal delivery system. It was hoped that this system would deliver analgesia more rapidly than oral narcotic or non-narcotic analgesics and as effectively as more commonly used parenteral analgesics. MATERIALS AND METHODS This was a prospective, open-label, uncontrolled study using a flexible dosing schedule. A convenience sample of adult patients with muscuioskeletal or soft tissue injuries were eligible for partic- ipation. All patients were assessed by an attending level emergency physician, and those found to have pain that was severe enough to warrant the administration of parenteral narcotic analgesics were eligible for inclusion. Patients were excluded who reported hyper- sensitivity to narcotic analgesics, a history of ethanol or drug abuse, a history of a recent head injury or a seizure disorder. Pregnant or nursing women were also excluded. In addition to a standard com- plaint-relevant physical examination, patients had an examination of their nasal mucosa before and after the study medication was ad- ministered. This study was approved by the hospital’s human sub- jects research committee, and all patients signed a written consent to participate. Butorphanol was administered by a patient-operated, metered- dose spray pump under the supervision of a study nurse. The initial dose was 1 mg and subsequent doses of 0.5 to 1 mg were adminis- tered at 30-minute intervals as needed for relief of pain. The maxi- mum total dose in 2 hours was not to exceed 3 mg. Before being used by the patient, the pump was primed and weighed four times to ensure accurate dose delivery. It was again weighed after the patient completed the study to document actual total dose delivered. Pa- tients were allowed to receive a rescue medication if the pain was not relieved within 1 hour, 15 minutes after the initial dose. Before receiving medication, patients were asked to rate their pain on a Likert scale of severe, moderate, or mild. During the 3-hour study, they were asked to rate their pain relief as complete, a lot, some, a little, or none. Time intervals for evaluation were 5, 15, 30, 60, 90, 120, and 180 minutes after the initial dose. At these same intervals patients were asked if they had a 50% reduction in pain. At the conclusion of the study period, patients were asked for a global assessment of the medication as excellent, very good, good, fair, or poor. A second global assessment of overall efficacy was performed by the study nurse. Because there were no comparisons. no statistical evaluation was undertaken. 469