Pain Assessment and Management

• Inaccurate pain assessment often leads to inadequate pain treatment
• Pain perception is subjective and influenced by cognitive and emotional states
• Pain perception is not directly proportional to injury severity
• Communication barriers complicate pain assessment

At-Risk Groups for Oligoanalgesia

• Infants
• Children
• Non-native language speakers
• Developmentally delayed individuals
• The mentally ill
• Racial/ethnic minorities

Reasons for Inadequate Analgesia

• Ineffective pain assessment
• Misconceptions about treatment safety
• Delays during high-volume periods
• Subtherapeutic opioid dosing

FACES Pain Scale

• Appropriate for children under 7 years old
• Uses cartoon faces to represent pain intensity
• Requires less abstract reasoning compared to numeric scales
• Valid for toddlers and cognitively impaired adults

Observer-Derived Pain Scales

• Provide reproducible scores for preverbal children in research
• Less clinically useful than clinician/parental impression in practice

Pain Treatment Goals

• Reduce pain by 50%
• Achieve a score of less than 4/10
• Categorize pain as mild, moderate, or severe
• Avoid targeting maximum analgesic doses

Four Treatment Groups for Pain Management

• Acute pain
• Recurrent pain
• Chronic pain of malignancy or neuropathic origin
• Chronic pain that is nonmalignant

Acute vs Chronic Pain Management in the ED

• Acute pain: Rapid titration of analgesics.
• Chronic pain: Multidisciplinary, long-term focus, avoid opioids unless malignancy-related, transition to baseline therapy for exacerbations

ED Interventions for Chronic Pain Patients with Treatment Gap

• Start acetaminophen + NSAID if tolerated
• Add neuropathic adjuvants like gabapentin
• Avoid opioids unless verified by the patient's pain management clinician

Opioids and Chronic Nonmalignant Pain

• Opioids are rarely indicated
• Chronic opioid use requires longitudinal monitoring
• Emphasize multimodal therapies like physical rehab, psychological support and avoid contributing to dependency

Recurrent pain

• Defined by repeated episodes like migraines or sickle cell crises
• Managed by treating acute flares while integrating preventive strategies like physical therapy or prophylactic medications

Chronic Malignant Pain in the ED

• Liberally use long-acting or transdermal opioids
• Evaluate new pain patterns for underlying causes like metastasis
• Address psychosocial impacts

Medications for Complex Regional Pain Syndrome (CRPS)

• Gabapentin is first-line
• Pregabalin is used if sedation is intolerable
• Avoid opioids
• Clonidine and NMDA antagonists like ketamine are alternatives

Opioid-Induced Constipation

• Mechanism: Opioid receptors in the gut slow motility.
• Management: Prescribe stimulant laxatives like senna or bisacodyl prophylactically for long-term use (more than 3–5 days).

IV Opioid Titration

• IV preferred over IM for severe acute pain
• IV allows precise dosing adjustments every 5–15 minutes
• IM absorption is variable, delaying relief and risking overdose if repeated prematurely

Risks of Combining Opioids with Benzodiazepines

• Synergistic respiratory depression
• Use cautiously in patients with hepatic/renal impairment, shock, or elderly patients due to metabolite accumulation

Behaviors Specific to Opioid Addiction

• Injecting oral formulations
• Selling prescriptions
• Forgery
• Escalating doses without approval
• Obtaining drugs illegally
• Functional decline

Prescription Monitoring Programs

• They reduce opioid misuse
• They track prescription history across providers
• They identify high-risk patterns like "doctor shopping"
• Some states mandate registry checks pre-prescribing

Opioid Prescriptions for Acute Fractures

• Recommended duration is 3-5 days, pending outpatient follow-up
• Avoid refills to prevent misuse
• Transition to NSAIDs/acetaminophen as pain diminishes

Pain and Respiratory Depression

• Pain stimulates respiratory drive therefore mitigating opiod induced repsiratory depression
• Risk increases post-pain relief such as after fracture reduction
• Monitor closely and titrate cautiously

Tolerance vs Addiction

• Tolerance: Diminished effect over time which is expected.
• Addiction: Compulsive use despite harm and craving. Physical dependence is not addiction

Antiemetics for Opioid-Associated Nausea

• Promethazine 12.5-25 mg IV/IM
• Prochlorperazine 5-10 mg IV/IM
• Ondansetron 4–8 mg IV.
• Avoid routine prophylaxis and treat as needed

Nonpharmacologic Therapies for Chronic Pain

• Physical rehab
• Interventional procedures like nerve blocks
• Cognitive-behavioral therapy
• Integrative approaches like acupuncture

Mechanism of Opioid-Induced Pruritus

• Histamine release from mast cell activation via opioid receptors
• It is not an allergic reaction

Opioids to Avoid in Renal Impairment

• Morphine (accumulates as morphine-6-glucuronide)
• Meperidine (neurotoxic normeperidine metabolite)

Risk of Repeated Meperidine Use

• Accumulation of normeperidine
• It can cause seizures or tremors, especially in renal impairment

Transdermal Fentanyl

• Inappropriate for acute pain
• Slow onset of 12–24 hours to peak
• Reserved for chronic cancer pain

Naloxone

• Role of naloxone in opioid-induced respiratory depression
• Titrate 0.04-0.4 mg IV to reverse respiratory depression while preserving analgesia

Opioids and Reactive Airway Disease

• Fentanyl is safer because it has minimal histamine release
• Avoid morphine due to risk of bronchospasm

IV Opioid Titration Advantage

• Precise dosing adjustments every 5-15 minutes until analgesia is achieved

Maximum Acetaminophen Dose

• For adults with normal liver function: 4 g/day
• 3 g/day if chronic use or alcohol history

NSAIDs and Renal Colic

• NSAIDs, like ketorolac, are recommended
• They reduce ureteral spasm and inflammation better than opioids

Diabetic Neuropathy Therapy

• First-line therapy: Gabapentin or carbamazepine for lancinating or burning pain

CRPS Type 1 vs Type 2

• Type 1: No nerve injury with sympathetic symptoms
• Type 2: Specific nerve injury

Opioids and CRPS

• Opioids are ineffective for CRPS
• CRPS involves central sensitization and NMDA activation
• Use gabapentin, clonidine, or NMDA antagonists

Ketamine in Acute Pain

• Use low-dose IV 0.1-0.3 mg/kg as an opioid adjunct
• It reduces central sensitization

Opioid Respiratory Depression

• Patients at highest risk
  • Opioid-naïve patients
  • Hepatic/renal impairment patients
  • Concurrent sedatives patients
  • Post-pain relief patients

Sickle Cell Pain Crisis Management

• Aggressive IV opioids like morphine/hydromorphone + NSAIDs
• Avoid meperidine

Antidepressants for Neuropathic Pain

• Use SSRIs like selective serotonin reuptake inhibitors for non-neuropathic chronic pain

Anticonvulsants for Neuropathic Pain

• Gabapentin, carbamazepine, phenytoin, valproic acid for lancinating or burning pain

Drug-Seeking Behavior

• Injecting oral drugs
• Prescription forgery
• Obtaining drugs illegally
• Selling prescriptions

Opioid Prescription Duration for Acute Fractures

• 3-5 days pending outpatient follow-up
• Avoid refills to prevent misuse