Pain Control Measures in the ED Shifting Away From Opioids

HOLLYWOOD, Fla.—Some illicit substances seen among patients presenting to the emergency department (ED) with drug overdoses have remained constant over the past several years, such as alcohol, opioids and fentanyl, methamphetamine, and cocaine, a speaker said during the 2023 annual meeting of the American Society of Regional Anesthesia and Pain Medicine. But they’re still important for anesthesiologists to track so they know how to address pain control either in the ED or operating room.

A newer trend has been the emergence of patients presenting with use of xylazine, a horse tranquilizer, said Arun Nagdev, MD, the director of emergency ultrasound at Highland Hospital in Oakland, Calif., and an associate clinical professor at the UCSF School of Medicine, in San Francisco. “It’s not purposeful but mixed in with other opioids they’re using,” Nagdev told Pain Medicine News. The fentanyl crisis also continues, he said.

Emergency physicians employ various techniques to stabilize patients with drug overdose, Nagdev said. For example, opioid patients can be given naloxone. For patients who come in violent or agitated, dopaminergic (D2) blockade with agents such as haloperidol or benzodiazepines is helpful. Ketamine, another option, is “a really wonderful drug for the patient that’s completely out of control,” he said, especially for trauma patients for whom ED physicians need rapid imaging tests or stabilization and don’t have 10 minutes to wait for a benzodiazepine to kick in. Studies (Ann Emerg Med 2021;78[6]:788-795) have shown ketamine to be safe and effective. Patients are given a dissociative dose (up to 4-5 mg/kg intramuscular) and are simultaneously watched and stabilized.

“It’s become the biggest tool that we now employ,” Nagdev said. “People who come in out of control and extremely agitated, we can give one 4- to 5-mg/kg intramuscular injection and in about two to three minutes, they’re calm and sleeping.”

Pain treatment in the ED overall has shifted from use of opioids as first-line therapy to a multimodal approach that uses 400 mg of ibuprofen and 1,000 mg of acetaminophen first, then a low dose of oral opioids such as morphine if needed, he said. Oral morphine has limited absorption in the gut, so patients don’t feel high.

Other options used in the ED for pain control with good efficacy include IV ketorolac and low-dose or continuous infusion ketamine, Nagdev said. For patients who don’t achieve pain control with nonsteroidal anti-inflammatory drugs, 20 to 30 mg of ketamine on a slow drip works well, perhaps better than morphine (Ann Emerg Med 2015;66[3]:222-229).

“It’s become my new option for pain control for patients with a range of issues such as kidney stones, appendicitis, sickle cell crises and broken bones,” he said of ketamine. “Intranasal ketamine could be helpful for pediatric patients or adults in an ambulance who don’t have an IV line in place.”

Medically assisted treatment for opioid abuse is also becoming more common in the ED setting, Nagdev said. At his hospital, patients are given an initial dose of oral buprenorphine in the waiting room to start feeling better, then are given a prescription for buprenorphine and referred directly to an outpatient clinic or are counseled by a substance abuse navigator before discharge (Ann Emerg Med 2023;81[3]:297-308).

—Karen Blum

Nagdev reported no relevant financial disclosures.