Acute Pain Management in the ED

1. When considering opioids for acute pain:
     a. Counsel on serious adverse effects such as:
          i. Sedation and respiratory depression
          ii. Pruritus and constipation
          iii. Rapid development of tolerance, addiction, and hyperalgesia
      b. Combine opioids with non-opioid pharmacological therapies
      c. Access your state's Prescription Drug Monitoring Program

2. When you have decided on IV opioids for acute pain:
      a. You must titrate opioids until optimization is achieved (better functional status) or until side effects or intolerable
      b. Avoid IM injections → unpredictable absorption rates, need for dose escalation, can lead to muscle necrosis
      c. Morphine provides best balance of analgesic efficacy and safety among IV opioid
      d. Avoid Dilaudid as a first-line opioid due to higher euphoria rates, addicition and respiratory depression needing reversal
      e. Start with lower than recommended dose of opioids in renal failure patients
      f. Opioid-induced pruritus is mediated via μ-opioid receptors and without histamine release; treat this with low-dose naloxone → 0.25 to 1 mcg/kg/h

Dr. Motov's Opioid Alternatives References:
Dr. Sergey Motov. “Pitfalls of Acute Pain Management in the ED: Opioids, Non-opioids, and then some…” Cooper University Hospital Emergency Department Grand Rounds. Cooper University Hospital. February 2018