Are you under treating pain in your ED?

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For analgesics, the sky’s the limit.

A pet peeve of mine when placing orders in my hospital’s EMR is the default dosing of some of our analgesic medications. The system automatically orders 600 mg, 650 mg and 4 mg for ibuprofen, acetaminophen and morphine, respectively.

I’ve always been taught the maximum single doses of these medications are 800 mg, 1000 mg and 0.1 mg/kg of ideal body weight, so having to go back and adjust these in order to sufficiently treat my patients’ pain is an irksome inconvenience.


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I was therefore quite intrigued when I came across an article in this magazine which described an “analgesic ceiling” for ibuprofen dosing. It reviewed a study that compared 400 mg, 600 mg and 800 mg doses of ibuprofen for patients in the emergency department with acute pain.[1]

They found no difference in pain relief at 60 minutes post-administration. The study’s authors conclude that there is no benefit to giving more than 400 mg of ibuprofen, and that doing so may in fact lead to increased side effects.

To this I would respond with a tongue-in-cheek slogan of one of my attendings: “In order to have side effects, a medication has to have an effect.” Why, if we conclude that there is no increase in analgesia past doses of 400 mg of ibuprofen, would we also conclude that there is an increase in adverse effects past 400 mg? This logic, I don’t quite follow. In fact, the study itself found no clinically adverse reactions with any of the three doses.


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Treat ‘em and Street ‘em

What’s more, I’m also interested in the analgesic response after 60 minutes. The study’s own authors concede that due to the linear kinetic properties of ibuprofen, a larger dose may actually lead to longer and more sustained analgesia. If so, then why wasn’t monitoring this variable part of the study?

I’m afraid we are throwing the baby out with the bathwater, and the almighty dispo is hamstringing us into this minimalist, do-the-least-possible attitude. Yes, I want the most effective dose to treat my patients’ pain while in the emergency department while minimizing potential adverse effects, but I think we emergency physicians should also be as interested in our patients’ analgesia once they leave our department as well as when they are in it.

This limitation isn’t unique to this study. Another study, published in 2017, showed no difference at 30 minutes and two hours with 10 mg, 15 mg and 30 mg doses of intravenous ketorolac.[2]


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Once again we should ask ourselves, would a higher dose lead to a more sustained reduction in pain, even if its magnitude of analgesia may be no greater? This study also recorded adverse effects and, unsurprisingly, found no difference between the three dosage groups.

Other studies have shown only a small increased risk of adverse effects with ketorolac if therapy is limited to less than five days.[3] Considering I have never prescribed ketorolac to be taken at home, I would think any harm from a single dose in the ED to be fairly minimal.

I often instruct patients, who present with pain and are discharged, to take scheduled ibuprofen and acetaminophen three times a day for the next three to five days in order to control their pain until they can follow up or their pain is resolved. I’d be interested to see a study evaluating the effect this strategy has on patients’ pain once they leave the emergency department.

Would multiple 400 mg doses of ibuprofen still be equivalent to the same regimen of 800 mg over the course of several days? If a high quality study did in fact show this, I may then be convinced to abandon my “go big or go home” approach of prescribing analgesia (though if I am discharging these patients, maybe it is more aptly named a “go big and go home” approach?).

Until then, I find the theoretical benefit of longer lasting analgesia outweighs the theoretical downside of increased risk of adverse events in the average ED patient (especially if said analgesia is for a short, few-day course).

Missing the Forest for the Trees

What I find is often missed with these “opiate-sparing” and “dose reduction” strategies is one important point: it is very easy to under-treat pain in the emergency department. Considering that pain is the most common chief complaint in the ED, I think our focus should be more on maximizing analgesia by any means than on minimizing potential side effects of adequate analgesia, at least in the short term.

Several studies have demonstrated the issue of oligoanalgesia in the Emergency Department. One found that among patients with acute fractures, as many as 70% received no pain medication.[4] Another study found that over half of all patients who presented with painful conditions received no analgesia while in the ED, and among those who did, over 40% had to wait more than two hours to do so, and almost a third received less than the optimal dose of narcotic pain medication.[5]

What’s more, ED nurses and physicians consistently perceive patients’ pain to be less than what the patients themselves experience.[6,7] Add to this the fact that people of color are more likely than white patients to receive analgesia in the ED,[8] and it’s evident that we as emergency physicians have much room for improvement with respect to adequately and equitably treating our patients pain.

Conclusion

While I commend efforts to minimize any harm our therapies may have on patients, I remain unconvinced that using the maximum recommended dose of NSAIDs in the Emergency Department will have a net negative effect on them. In fact, given the systemic issue of oligoanalgesia in the ED, I’ll happily stick with 800 mg of ibuprofen, whether it be for my patients or myself.

References:

  1. Motov S, Masoudi A, Drapkin J, et al. Comparison of Oral Ibuprofen at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2019;74(4):530-537. doi:10.1016/j.annemergmed.2019.05.037
  2. Motov S, Yasavolian M, Likourezos A, et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2017;70(2):177-184. doi:10.1016/j.annemergmed.2016.10.014
  3. Strom BL, Berlin JA, Kinman JL, et al. Parenteral ketorolac and risk of gastrointestinal and operative site bleeding. A postmarketing surveillance study. JAMA. 1996;275(5):376-382.
  4. Lewis LM, Lasater LC, Brooks CB. Are emergency physicians too stingy with analgesics?. South Med J. 1994;87(1):7-9. doi:10.1097/00007611-199401000-00002
  5. Wilson JE, Pendleton JM. Oligoanalgesia in the emergency department. Am J Emerg Med. 1989;7(6):620-623. doi:10.1016/0735-6757(89)90286-6
  6. Guru V, Dubinsky I. The patient vs. caregiver perception of acute pain in the emergency department. J Emerg Med. 2000;18(1):7-12. doi:10.1016/s0736-4679(99)00153-5
  7. Stalnikowicz R, Mahamid R, Kaspi S, Brezis M. Undertreatment of acute pain in the emergency department: a challenge. Int J Qual Health Care. 2005;17(2):173-176. doi:10.1093/intqhc/mzi022
  8. Todd KH, Deaton C, D’Adamo AP, Goe L. Ethnicity and analgesic practice. Ann Emerg Med. 2000;35(1):11-16. doi:10.1016/s0196-0644(00)70099-0

ABOUT THE AUTHOR

Dr. Cunningham is an emergency medicine resident at Maricopa Medical Center with interests in critical care, airway management and Oxford commas.

2 Comments

  1. So many of these studies are half-hearted, and do not study the entire problem for the entire time of action. In fact, to me it seems that many of these studies are arranged to give a pre-conceived conclusion instead of truly studying the entire problem for the entire time of duration. That’s the problem with half-hearted studies: are they due to ignorance or to a pre-arranged conclusion that will agree with conventional wisdom? IDK!

  2. Russell Leewood on

    Great article
    These studies will be debunked in years to come just the way vitamin e was in the past

    There are no objective measures of pain so I
    dispute whether a certain dose is more or less effective- it is in the eye of the beholder ( the patient)

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