Optimizing the Treatment of Acute Pain in the Emergency Department
Approved by the ACEP Board of Directors April 2017
Replaces 2009 policy titled “Optimizing the Treatment of Pain in Patients with Acute Presentations” rescinded by the ACEP Board of Directors April 2017
The American College of Emergency Physicians seeks to improve
acute pain management for patients in the emergency department (ED) and
recognizes the need for prompt, safe, and effective pain management. Although a very important topic,
treatment of patients with chronic pain, especially those receiving hospice,
palliative or end-of-life care, is beyond the scope of this document.
acute pain management is patient-specific and pain syndrome-targeted when
feasible, using a multimodal approach that includes pharmacological and
Base the assessment of pain and need for therapy on an overall accounting of
patient status, including functional assessment, rather than solely on patient
reported pain scores.
Management in the ED
treatment of many acutely painful conditions should optimally begin with
a non-opioid agent.
Choose non-steroidal anti-inflammatory drugs
(NSAIDs) based on their analgesic ceiling dose (which is lower than the
anti-inflammatory maximal doses) and prescribe at the lowest effective dose for
the shortest expected duration to avoid complications. Use NSAIDs with added
caution in those with pre-existing renal insufficiency, heart failure, a
predisposition to gastrointestinal hemorrhage, and in elderly patients.
Oral (or rectal) acetaminophen is a good initial
analgesic for mild-moderate pain. Intravenous acetaminophen (APAP) has similar
effects as oral, however is much more expensive, making it best reserved for
those who cannot take medications by mouth or per rectum.1
Regional anesthesia (nerve blocks), with or
without ultrasound guidance, may be used for certain acutely painful
conditions, either alone or as part of a multimodal approach to pain relief.
Administration of sub-dissociative dose ketamine
(SDK) may be used either alone or as part of a multimodal approach to pain
relief for traumatic and non-traumatic pain. Emergency care providers should
disclose to patients that SDK administration may trigger generally minor,
transient side effects. Administration of
sub-dissociative ketamine should commence under the same procedures and
policies as other analgesic agents administered by the nursing staff in the ED
Intravenous lidocaine may be beneficial for
specific, acutely painful conditions (e.g., renal colic, acute radicular back
pain, herpetic/post-herpetic neuralgia) in patients without known structural
heart disease or rhythm disturbances.
Topical lidocaine patches may be used for certain
pain syndromes, such as post-herpetic neuropathic pain and myofascial pain.
Opioid analgesics are commonly used to manage
acute severe pain in the ED as well as pain refractory to non-opioids. Before
prescribing, assess risks of harm and counsel patients regarding serious
adverse effects, such as sedation, respiratory depression, risk of tolerance
and hyperalgesia, and potential risk of opioid use disorder. Risks of co-prescribing opioids
with other CNS depressants, such as benzodiazepines, and the patient's
individual risk of abuse should also be considered.
o Patients can
benefit from knowing opioid alternatives before receiving these agents,
allowing shared analgesic planning.
o In severe acute
pain, titrate parenteral opioids in incremental doses based on response
targeting comfort and function rather than complete pain relief.
o As a general
principle, those being prescribed opioids should only receive immediate-release
opioids in the lowest effective dose for the shortest reasonably practical
o Emergency care
providers should generally not initiate therapy with extended-release (ER)
(e.g., OxyContin, Opana ER, fentanyl patch) or long-acting (LA) opioids (eg,
presenting to the ED for acute exacerbation of chronic pain should generally
not receive an opioid analgesic or opioid prescription. When feasible,
coordinate treatment with the patient’s primary pain management provider.
Individualized treatment plans and contracts may be effectively used to guide
treatment. If deemed necessary, the emergency care provider should only
prescribe the minimal amount needed for a reasonable follow-up interval.
programs allow emergency providers to identify and counsel patients with
aberrant use patterns; this helps limit opioid abuse potential and identify
those who may benefit from addiction treatment.2
o Patients should
also be counseled about safe medication storage and disposal.
Given the adverse effects associated with many
analgesics, it is particularly important to understand and employ
non-pharmacologic treatments, including patient-centered communication
techniques, physical interventions, ice/heat, topical coolant sprays, recommendations for activity and exercise, and
relaxation techniques. Effective use of these modalities can improve care and
lessen risk of harm from pharmacologic therapy.
communication is a core competency for emergency care providers.
Patient-physician interactions characterized by empathy and trust are more
likely to lead to optimal outcomes.3
Mind-body therapies (MBT), alone or in
combination with other modalities, have documented efficacy in the management
of some types of pain; however, there is no evidence regarding their efficacy
for ED patients.4-6
There is a need for well-designed studies that
examine the effect of behavioral therapy in the treatment of pain in ED
is a state of adaptation in which exposure to a drug induces changes that
result in a diminution of one or more of the drug’s effects over time."8
Dependence: Physical dependence is a state of
adaptation that often includes tolerance and is manifested by a drug class
specific withdrawal syndrome that can be produced by abrupt cessation, rapid
dose reduction, decreasing blood level of the drug, and/or administration of an
is a primary, chronic, neurobiological disease, with genetic, psychosocial, and
environmental factors influencing its development and manifestations. It is
characterized by behaviors that include one or more of the following: impaired
control over drug use, compulsive use, continued use despite harm, and craving.8
“Opioid-induced hyperalgesia”: "Opioid-induced
hyperalgesia (OIH) is defined as a state of nociceptive sensitization caused by
exposure to opioids. The condition is characterized by a paradoxical response
whereby a patient receiving opioids for the treatment of pain could actually
become more sensitive to certain painful stimuli.”9 OIH is difficult
to differentiate from tolerance and cannot be reliably diagnosed in the ED.
Pain related to acute injury, harm or repair, and often shorter duration
(typically less than 30 days). The cause may be known or unknown. Acute pain
usually occurs as part of a single and treatable event. It is often (not
always) associated with autonomic nervous system responses (tachycardia, hypertension,
diaphoresis). Acute pain typically decreases with time.
diagnoses that are associated with acute pain include the following: long bone
fractures, appendicitis, burns, and procedural pain.
exacerbation of a recurring painful condition: Pain
can occur over any duration of time. Pain is due to chronic organic
nonmalignant pathology. Examples of diagnoses that include acute exacerbation
of a recurring painful condition are the following: sickle cell pain episodes
and migraine headache. There are pain free episodes between the exacerbations.
pain: Chronic (persistent) pain is pain
that lasts longer than the expected time of healing. There is continuous pain
or the pain recurs at intervals for months or years. In some cases, there are
acute exacerbations of chronic pain problems. The cause is often unknown.
Examples of chronic/persistent pain include the following: low back pain,
diabetic neuropathy, post herpetic neuralgia, multiple sclerosis, and phantom
Cancer pain: Pain
caused by "conditions that are potentially life-threatening." The
causes of cancer pain are cancer itself, treatment of cancer, and concurrent
disease. Examples of cancer pain include the following: cancer of the pancreas,
spinal cord compression caused by tumor infiltration, postsurgical pain
associated with cancer treatment, and post mastectomy syndrome.
Sin B, Wai M, Tatunchak T,
et al. The use of intravenous acetaminophen for acute pain in the
emergency department. Acad Emerg Med. 2016;23(5):543-553.
Larochelle MR, Liebschutz
JM, Zhang F, et al. Opioid prescribing after nonfatal overdose and association with
repeated overdose: A cohort study. Ann
Intern Med. 2016;164(1):1-9.
Kelm Z, Womer J, Walter JK, et al. Interventions
to cultivate physician empathy: a systematic review. BMC Med Educ. 2014;14:219.
Penzien DB, Irby MB, Smitherman TA, et al.
Well-established and empirically supported behavioral treatments for migraine. Curr Pain Headache Rep. 2015;19(7):34.
Theadom A, Cropley M, Smith HE, et al. Mind and
body therapy for fibromyalgia. Cochrane
Database Syst Rev. 2015;9(4).:CD001980.
Hoffman BM, Papas RK, Chatkoff DK, et al.
Meta-analysis of psychological interventions for chronic low back pain. Health Psychol. 2007;26(1):1-9.
Lee C, Crawford C, Hickey A. Mind-body therapies
for the self-management of chronic pain symptoms. Pain Med. 2014;15 Suppl 1:S21-39.
American Academy of Pain Medicine, the American
Pain Society, the American Society of Addiction Medicine (2001). Definitions related
to the use of opioids for the treatment of pain. WMJ. 2001;100(5):28-29.
Lee M, Silverman S, Hansen H, et al. A comprehensive
review of opioid-induced hyperalgesia. Pain
Physician. 2011 Mar-Apr;14(2):145-161.