Pain in the Emergency Department: Let's Elevate Our Game!

Unfortunately with the current opioid epidemic, practitioners across all subspecialties are looking to find alternatives to treat pain effectively and to not solely rely on opiates especially as a first line treatment. In the emergency department we see a variety of pain, some mild, some severe. For patients who have severe pain, opiates are fantastic modality to help relieve their suffering. From mild to moderate pain, ankle sprains or low back pain, it's important to not to reflexively prescribe opiates but to appreciate the tool box of medications we have for pain management. It's important in primary care and emergency medicine to utilize a multimodal approach to pain management and not solely rely on one medication to get the job done. Utilizing anti-inflammatory medication combined with acetaminophen has been shown to provide better pain relief than using either the anti-inflammatory or acetaminophen alone. Also appreciating topical medications and utilizing the skin as a modality for administration has been shown to be very effective. Things like diclofenac gel or lidocaine patches are a great way to elevate pain management and they can be easily administered and prescribed in an outpatient setting.

Another interesting modality that I discovered during my pain management fellowship was trigger point injection. We can perform that in the outpatient or emergency department setting. It's a matter of using a small gauge needle, putting it into the area of severe spasm that may actually feel like nodule and just by using the needle to break up that spasm, the patient will have immediate relief. Exploring this modality in a primary care setting will greatly improve pain management in the office and can provide immediate relief in ways that other modalities cannot. What's nice has been looking at the evidence and seeing the studies, and reading about patient experiences and appreciating that there's a lot of modalities that cross emergency care as well as primary care.

The most recent CDC guidelines that have been published were an effort to provide information about best practice for opiate prescribing for chronic pain. We know a lot more now than we did 10 or 15 years ago, and I appreciate the CDC's effort to educate physicians so that everyone can be on the same level playing field. In the emergency department, we do see a large population of people who are maintained on opiates at home for chronic pain. We have to appreciate that it's a delicate balance when prescribing opiates chronically, and then dealing with an acute flair in the emergency department. In the emergency department, the goal should be to clearly manage the acute issue, but then to collaborate and communicate with the prescribing physician from the community so that you are not adding benzodiazepine or other chronic opiates on top of what a patient is maintained on, because it sets the patient up for adverse events. So we really have to be a team in the emergency department with the primary care prescriber.