You must brace for change in ED pain management

There are a number of significant advancements in pain management that will impact your clinical practice, according to Paula Tanabe, RN, PhD, CCRN, CEN, research coordinator and research assistant professor for the division of emergency medicine at Northwestern Memorial Hospital and Feinberg School of Medicine in Chicago. Here are several:

More choices in analgesic agents.

There has been a great deal of recent attention to the cyclooxygenase (COX)-2 specific inhibitors, Tanabe reports. "Marketing efforts by the pharmaceutical companies have been very strong," she says. However, evaluation of the data reveals that these analgesic agents are no more effective than ibuprofen, and COX-2 inhibitors are significantly more costly, she adds.1 Oral analgesics containing acetaminophen and hydrocodone are being prescribed more frequently, says Tanabe.

She explains that Norco (Watson Pharmaceuticals, Corona, CA) is an excellent analgesic choice for patients who need to be discharged from the emergency department (ED) on stronger analgesics. The drug contains 10 mg of hydrocodone and 325 mg of acetaminophen. These are the same agents contained in the drug Vicodin (Abbott Laboratories, Abbott Park, IL), but in different amounts. Vicodin contains 5 mg of hydrocodone and 500 mg of acetaminophen, she says. "The advantage of Norco is that it provides double strength hydrocodone with less acetaminophen," says Tanabe. "Patients are frequently limited in the number of Vicodin that can be taken, because of the amount of acetaminophen."

Appropriate use of existing agents.

Tanabe says that she doesn’t expect to see many other "new" analgesic agents that will affect the ED. "However, I do believe that as ED physicians and nurses become more educated about pain management, EDs will begin to use more agents that are currently available," she predicts. (For more information on this topic, see "Out of compliance with standards? You must assess and treat pain quicker," ED Nursing, March 2000, p. 53.)

She gives the following examples:

— Hydromorphone is an excellent analgesic that is seven times as strong as morphine with similar duration of action, says Tanabe. "A common dose of hydromorphone is 0.5 to 1 mg. It is interesting that ED nurses are not reluctant to give 1 mg of hydromorphone, which is equivalent to morphine 7 mg," she says.

— Fentanyl is an analgesic with a short duration of action, says Tanabe. "This is an excellent choice for trauma patients, acute abdominal pain, and conscious sedation procedures," she says.

Decreased use of intramuscular administration.

The intramuscular route of administration will decrease, according to Pat Spurlock, RN, clinic administrator at Neurological Associates of Des Moines (IA) and former service line director for emergency services at Mercy Medical Center, also in Des Moines. "Titrating medications administered intravenously provides individualized, rapid pain relief without the greater risk of overmedicating patients," she explains.

Less use of meperidine.

Tanabe says she hopes that fewer EDs will continue to rely on meperidine as the analgesic agent of choice. Meperidine has an active metabolite with a long half life that is toxic to the central nervous system, she explains. "Morphine, hydromorphone, and fentanyl are much safer and more effective analgesics," says Tanabe.

More frequent use of other routes of administration.

Oral morphine and hydromorphone are both excellent choices for patients with severe pain and poor intravenous (IV) access, according to Tanabe. If you choose to administer these agents in an oral form, the correct equianalgesic dose must be administered, cautions Tanabe. She stresses that it is important to know the IV to oral equianalgesic conversion rates, as follows: Morphine 1 mg IV is equivalent to 3 mg orally. Hydromorphone 2 mg IV is equivalent to 8 mg orally. She adds that morphine sulfate immediate-release tablets are available in 15- and 30-mg dosages. "It is also important to remember that these oral forms peak in 60 minutes," she says. "Additional doses cannot be repeated prior to this time."

More use of patient-controlled analgesia (PCA) pumps.

Although not many EDs currently use PCA pumps, this will become more common, Tanabe predicts. "Some select patient populations may benefit from this method of analgesic administration," she says. "Sickle cell patients and some trauma patients may be candidates for PCA administration." (For more information on this topic, see "Give a PCA pump to patients in pain," EDN, December 2001, p. 27, and "Are your sickle cell patients in danger? Follow new pain management guide," EDN, July 2001, p. 113.)

Increased use of conscious sedation.

Spurlock says that conscious sedation with pharmacological agents previously used only in the surgical setting by anesthesiologists will continue to grow in the ED, both in adult and pediatric patient injuries. "Recovery time is less with patients reaching baseline in a shorter period of time, while still achieving the goal of pain relief with amnesiac benefits," she explains.

Tanabe foresees increased use of propofol, brevitol, and etomidate for conscious sedation procedures, which produce a deep sedation. "If these agents are given rapidly to reduce a dislocation, it’s possible that fewer analgesic agents will be needed," she says.

Reference

1. Silverstein FE, Faich G, Goldstein JL. Gastrointestinal toxicity with Celecoxib vs. nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis. JAMA 2000: 284;1,247-1,255.

Sources

For more information on pain management, contact:

Pat Spurlock, RN, Neurological Associates of Des Moines, 1601 N.W. 114th St., Suite 338, Des Moines, IA 50325. Telephone: (515) 223-1917. Fax: (515) 223-0284. E-mail: djtneuro@aol.com.

Paula Tanabe, RN, PhD, CCRN, CEN, Research Coordinator and Research Assistant Professor, Northwestern Memorial Hospital and Feinberg School of Medicine, Division of Emergency Medicine, 676 St. Clair, Suite 2125, Chicago, IL 60611. E-mail: ptanabe2@nmff.org.