Musculoskeletal injuries and diseases can be extremely painful, and a compassionate and thoughtful approach is required to provide adequate pain and anxiety relief. Depending on the patient’s underlying illness and clinical needs, the proper selection of type of analgesia and anxiolysis can have a significant impact on the outcome.
General Concepts for Pain Management
- 1
Pain reduction should be an early goal.
- 2
Pain reduction should be planned anticipating further management so as to improve, not impede, that management.
- 3
Modalities that work fast with the least systemic effects should be chosen.
- 4
Emergency department pain reduction should be transitioned to the outpatient or the inpatient pain management plan.
Analgesia
Mild Pain
Patients with acute traumatic or nontraumatic musculoskeletal complaints can be offered oral analgesia with acetaminophen (Tylenol) or a nonsteroidal anti-inflammatory drug (NSAID) early in presentation or in triage. These medications reduce pain with very few side effects, and there is no evidence that a single oral dose would impact further pain management, sedation, or anesthesia decisions.
Moderate Pain
Patients with more severe pain from acute traumatic or nontraumatic musculoskeletal complaints should be offered parenteral narcotic pain medications if there is no other method for better pain control. Pain medication generally should be administered before imaging studies and other diagnostic interventions. Better pain control methods may include splinting, ice, reduction of dislocation, hematoma block, arthro-block, or regional block.
Severe Pain
Trauma to an extremity with obviously deformed fractures or fracture-dislocations of the wrist, elbow, or ankle is best managed with early arthro-block or hematoma block and splinting for stability. Arthro-block or hematoma block offers excellent pain relief very quickly with no systemic side effects. Often there is no need for parenteral pain medication after adequate block. Patients with obvious or likely long bone fractures (i.e., hip, shoulder) or axial injuries (i.e., back, pelvis) are likely to require parenteral narcotic pain medications before studies. A patient with a clinically obvious simple dislocation often can undergo reduction before any studies are done. Reductions dramatically improve patients’ pain, reduce the risk of time-related complications of displacement, and reduce or eliminate the need for parenteral pain medications.
For nontraumatic injuries, when arthrocentesis is part of the diagnostic work-up, planning to place local anesthetic (lidocaine or bupivacaine without epinephrine with or without steroid) at the time of the therapeutic or diagnostic aspiration can greatly improve short-term pain relief and make examination for ligament stability and range of motion possible.
Mild Pain
Patients with acute traumatic or nontraumatic musculoskeletal complaints can be offered oral analgesia with acetaminophen (Tylenol) or a nonsteroidal anti-inflammatory drug (NSAID) early in presentation or in triage. These medications reduce pain with very few side effects, and there is no evidence that a single oral dose would impact further pain management, sedation, or anesthesia decisions.
Moderate Pain
Patients with more severe pain from acute traumatic or nontraumatic musculoskeletal complaints should be offered parenteral narcotic pain medications if there is no other method for better pain control. Pain medication generally should be administered before imaging studies and other diagnostic interventions. Better pain control methods may include splinting, ice, reduction of dislocation, hematoma block, arthro-block, or regional block.
Severe Pain
Trauma to an extremity with obviously deformed fractures or fracture-dislocations of the wrist, elbow, or ankle is best managed with early arthro-block or hematoma block and splinting for stability. Arthro-block or hematoma block offers excellent pain relief very quickly with no systemic side effects. Often there is no need for parenteral pain medication after adequate block. Patients with obvious or likely long bone fractures (i.e., hip, shoulder) or axial injuries (i.e., back, pelvis) are likely to require parenteral narcotic pain medications before studies. A patient with a clinically obvious simple dislocation often can undergo reduction before any studies are done. Reductions dramatically improve patients’ pain, reduce the risk of time-related complications of displacement, and reduce or eliminate the need for parenteral pain medications.
For nontraumatic injuries, when arthrocentesis is part of the diagnostic work-up, planning to place local anesthetic (lidocaine or bupivacaine without epinephrine with or without steroid) at the time of the therapeutic or diagnostic aspiration can greatly improve short-term pain relief and make examination for ligament stability and range of motion possible.
Medications for Pain
Opioids
For severe pain, patients may require initial dosing with intravenous opioids every 15 to 30 minutes to control pain. If the only routes available are intramuscular or subcutaneous routes, doses could be repeated every 30 to 60 minutes. The most common side effects with opioids include nausea, vomiting, sedation, delirium, hypotension, constipation, pruritus, urine retention, and respiratory depression.
Patients frequently claim to be opiate allergic, but careful discussion often reveals a side effect rather than a true allergic reaction. In this instance, switching to any other opioid may decrease the risk of side effects. Patients can develop diffuse pruritus and hives especially at an intravenous injection site. This side effect is most likely due to histamine release and can be controlled by an antihistamine.
Morphine
Morphine is the most commonly used parenteral opioid analgesic. The starting dose is 0.05 to 0.1 mg/kg (intravenous, intramuscular, or subcutaneous route). The analgesic equivalent oral dose is two to three times the parenteral dose. Morphine is available as immediate-release tablets, sustained-release tablets and capsules, liquid, liquid concentrate, and suppository. The liquid concentrate (20 mg/mL) can be given sublingually to provide analgesia. More recently, an abuse-resistant tablet Embeda (morphine with naltrexone) became available. Elderly patients and patients with impaired renal function require careful consideration for repeated doses of morphine because of decreased elimination. These metabolites provide analgesia but also cause nausea, vomiting, myoclonus, sedation, delirium, and respiratory depression.
Hydromorphone
The usual initial dose of hydromorphone is 0.0075 to 0.015 mg/kg (0.5 to 1 mg) administered intravenously, subcutaneously, or intramuscularly. The equivalent oral dose is approximately four times the parenteral dose. Parenteral hydromorphone is approximately five times more potent than parenteral morphine. Hydromorphone has only one weakly active metabolite, and it is a good choice in elderly patients and patients with impaired renal or liver function. It is available as an injection, immediate-release tablet, oral solution, suppository, and sustained-release tablet.
Fentanyl
The usual initial dose of fentanyl is 0.5 to 1 µg/kg administered intravenously, subcutaneously, or intramuscularly. It is a lipophilic drug, and it has a rapid onset and a short duration of action (<1 hour); this makes it easy to titrate and an excellent choice for patients who are likely to have significant improvement in their discomfort during the emergency department visit (i.e., pain is greatly reduced after joint reduction). Fentanyl is also well absorbed via the nasal route and the inhalation route, which has great utility in pediatric patients. Fentanyl has only minimally active metabolites, which coupled with its short duration of action makes it suitable for elderly patients and patients with liver disease or renal insufficiency.
Oxycodone
The usual dose of oxycodone is 5 to 10 mg in an immediate-release tablet. It is available as a sustained-release, tamper-resistant tablet (OxyContin); liquid; and liquid concentrate. The liquid concentrate (20 mg/mL) is useful for sublingual administration. Various commercial preparations of oxycodone with acetaminophen (different strengths) and ibuprofen are available.
Methadone
Methadone can be used for analgesia and to prevent opioid abuse. When used for analgesia, methadone needs to be given in divided doses (every 8 hours or every 6 hours). When used to prevent opioid abuse, it needs to be given only once per day. Methadone is generally not prescribed by emergency physicians.
Buprenorphine and Buprenorphine-Naloxone (Suboxone)
Buprenorphine is an opioid partial agonist. Buprenorphine and the combination of buprenorphine and naloxone are used to treat opioid addiction and are generally not prescribed by emergency physicians.
Non-Narcotic Pain Medications
Acetaminophen
Acetaminophen is widely available and useful as a nonprescription analgesic for mild to moderate pain and as an antipyretic. The usual adult dose is 650 mg orally or rectally every 4 hours as needed or 1 g every 6 hours as needed. The suggested maximum daily dose of acetaminophen at the present time is 4 g/day with a lower maximum dose (<2 g/day) for patients taking warfarin. Doses higher than 4 g/day can lead to hepatotoxicity. The combination of an NSAID with acetaminophen provides better analgesia for somatic and visceral pain than either agent alone.
Nonsteroidal Anti-inflammatory Drugs
Multiple NSAIDs are available to treat somatic and visceral pain. These agents do not work well for neuropathic pain. NSAIDs exert their pharmacologic effect by reversibly inhibiting prostaglandin formation through nonselective inhibition of cyclooxygenase enzymes I and II (COX-I and COX-II). Aspirin is the only NSAID that irreversibly binds to COX-I. COX-I is responsible for maintenance of normal physiologic functions (i.e., gastric mucosal barrier, platelet aggregation); COX-II is an inducible enzyme that is found at sites of tissue injury. If NSAIDs are prescribed, it is probably best to give them around-the-clock initially because NSAIDs inhibit a process from occurring: prostaglandin generation → cytokine release → edema, inflammation, and pain.
NSAIDs should not be given to patients after the 30th week of pregnancy, patients with congestive heart failure, or patients with renal dysfunction. Giving an NSAID to a patient who is already receiving a high-dose corticosteroid may lead to more toxicity without improved anti-inflammatory effects.
More recent publications indicate that NSAIDs may inhibit healing of bone fusions and fractures. Randomized controlled trials assessing the effect of NSAID exposure in patients with fractures, fusions, and osteotomies are needed to address these emerging concerns. It seems reasonable that NSAID use be avoided if possible for several months after the original incident or surgery in patients with risk factors for poor bone healing.
Ibuprofen
Ibuprofen is the classic NSAID. It is available as over-the-counter tablets (200 mg), prescription-strength tablets (400 mg, 600 mg, 800 mg), and suspension. The suggested maximum daily dose is 3200 mg divided in three to six doses.
Diclofenac
Diclofenac is one of the most potent NSAIDs and is available only by prescription. It is dosed every 12 hours and is available as 25-mg, 50-mg, and 75-mg tablets. Diclofenac does not seem to interfere with the cardioprotective effects of low-dose aspirin.
Naproxen
Naproxen is available over-the-counter as 220 mg and as prescription-strength 250-mg, 375-mg, and 500-mg tablets. It is usually given every 12 hours with a maximum dose of 1000 mg/day.
Ketorolac
Ketorolac was the first parenteral NSAID available; however, it is not more effective than an equipotent dose of other oral NSAIDs. The dose is 15 to 30 mg intravenously or intramuscularly every 6 hours or 10 mg orally every 6 hours. An intravenous bolus dose can be given over 30 to 60 seconds. The maximum parenteral dose is 120 mg/day, and the maximum oral dose is 40 mg daily. Patients older than 65 years or weighing less than 50 kg should receive a maximum dose of 15 mg every 6 hours. Ketorolac is contraindicated in patients with advanced renal impairment.
Celecoxib
At the present time, celecoxib is the only highly selective COX-II inhibitor on the market. Other COX-II inhibitors were withdrawn from the market owing to a risk of cardiovascular disease. Celecoxib has a slightly lower incidence of gastric and duodenal ulcers compared with nonselective COX inhibitors. The normal dose is 100 to 200 mg daily up to 200 mg every 12 hours. It has no effect on platelet aggregation. Celecoxib is used as part of many preoperative preemptive analgesic regimens for hip and knee replacements owing to its opioid-sparing effect and lack of platelet effects.
Opioids
For severe pain, patients may require initial dosing with intravenous opioids every 15 to 30 minutes to control pain. If the only routes available are intramuscular or subcutaneous routes, doses could be repeated every 30 to 60 minutes. The most common side effects with opioids include nausea, vomiting, sedation, delirium, hypotension, constipation, pruritus, urine retention, and respiratory depression.
Patients frequently claim to be opiate allergic, but careful discussion often reveals a side effect rather than a true allergic reaction. In this instance, switching to any other opioid may decrease the risk of side effects. Patients can develop diffuse pruritus and hives especially at an intravenous injection site. This side effect is most likely due to histamine release and can be controlled by an antihistamine.
Morphine
Morphine is the most commonly used parenteral opioid analgesic. The starting dose is 0.05 to 0.1 mg/kg (intravenous, intramuscular, or subcutaneous route). The analgesic equivalent oral dose is two to three times the parenteral dose. Morphine is available as immediate-release tablets, sustained-release tablets and capsules, liquid, liquid concentrate, and suppository. The liquid concentrate (20 mg/mL) can be given sublingually to provide analgesia. More recently, an abuse-resistant tablet Embeda (morphine with naltrexone) became available. Elderly patients and patients with impaired renal function require careful consideration for repeated doses of morphine because of decreased elimination. These metabolites provide analgesia but also cause nausea, vomiting, myoclonus, sedation, delirium, and respiratory depression.
Hydromorphone
The usual initial dose of hydromorphone is 0.0075 to 0.015 mg/kg (0.5 to 1 mg) administered intravenously, subcutaneously, or intramuscularly. The equivalent oral dose is approximately four times the parenteral dose. Parenteral hydromorphone is approximately five times more potent than parenteral morphine. Hydromorphone has only one weakly active metabolite, and it is a good choice in elderly patients and patients with impaired renal or liver function. It is available as an injection, immediate-release tablet, oral solution, suppository, and sustained-release tablet.
Fentanyl
The usual initial dose of fentanyl is 0.5 to 1 µg/kg administered intravenously, subcutaneously, or intramuscularly. It is a lipophilic drug, and it has a rapid onset and a short duration of action (<1 hour); this makes it easy to titrate and an excellent choice for patients who are likely to have significant improvement in their discomfort during the emergency department visit (i.e., pain is greatly reduced after joint reduction). Fentanyl is also well absorbed via the nasal route and the inhalation route, which has great utility in pediatric patients. Fentanyl has only minimally active metabolites, which coupled with its short duration of action makes it suitable for elderly patients and patients with liver disease or renal insufficiency.
Oxycodone
The usual dose of oxycodone is 5 to 10 mg in an immediate-release tablet. It is available as a sustained-release, tamper-resistant tablet (OxyContin); liquid; and liquid concentrate. The liquid concentrate (20 mg/mL) is useful for sublingual administration. Various commercial preparations of oxycodone with acetaminophen (different strengths) and ibuprofen are available.
Methadone
Methadone can be used for analgesia and to prevent opioid abuse. When used for analgesia, methadone needs to be given in divided doses (every 8 hours or every 6 hours). When used to prevent opioid abuse, it needs to be given only once per day. Methadone is generally not prescribed by emergency physicians.
Buprenorphine and Buprenorphine-Naloxone (Suboxone)
Buprenorphine is an opioid partial agonist. Buprenorphine and the combination of buprenorphine and naloxone are used to treat opioid addiction and are generally not prescribed by emergency physicians.
Morphine
Morphine is the most commonly used parenteral opioid analgesic. The starting dose is 0.05 to 0.1 mg/kg (intravenous, intramuscular, or subcutaneous route). The analgesic equivalent oral dose is two to three times the parenteral dose. Morphine is available as immediate-release tablets, sustained-release tablets and capsules, liquid, liquid concentrate, and suppository. The liquid concentrate (20 mg/mL) can be given sublingually to provide analgesia. More recently, an abuse-resistant tablet Embeda (morphine with naltrexone) became available. Elderly patients and patients with impaired renal function require careful consideration for repeated doses of morphine because of decreased elimination. These metabolites provide analgesia but also cause nausea, vomiting, myoclonus, sedation, delirium, and respiratory depression.
Hydromorphone
The usual initial dose of hydromorphone is 0.0075 to 0.015 mg/kg (0.5 to 1 mg) administered intravenously, subcutaneously, or intramuscularly. The equivalent oral dose is approximately four times the parenteral dose. Parenteral hydromorphone is approximately five times more potent than parenteral morphine. Hydromorphone has only one weakly active metabolite, and it is a good choice in elderly patients and patients with impaired renal or liver function. It is available as an injection, immediate-release tablet, oral solution, suppository, and sustained-release tablet.
Fentanyl
The usual initial dose of fentanyl is 0.5 to 1 µg/kg administered intravenously, subcutaneously, or intramuscularly. It is a lipophilic drug, and it has a rapid onset and a short duration of action (<1 hour); this makes it easy to titrate and an excellent choice for patients who are likely to have significant improvement in their discomfort during the emergency department visit (i.e., pain is greatly reduced after joint reduction). Fentanyl is also well absorbed via the nasal route and the inhalation route, which has great utility in pediatric patients. Fentanyl has only minimally active metabolites, which coupled with its short duration of action makes it suitable for elderly patients and patients with liver disease or renal insufficiency.
Oxycodone
The usual dose of oxycodone is 5 to 10 mg in an immediate-release tablet. It is available as a sustained-release, tamper-resistant tablet (OxyContin); liquid; and liquid concentrate. The liquid concentrate (20 mg/mL) is useful for sublingual administration. Various commercial preparations of oxycodone with acetaminophen (different strengths) and ibuprofen are available.
Methadone
Methadone can be used for analgesia and to prevent opioid abuse. When used for analgesia, methadone needs to be given in divided doses (every 8 hours or every 6 hours). When used to prevent opioid abuse, it needs to be given only once per day. Methadone is generally not prescribed by emergency physicians.
Non-Narcotic Pain Medications
Acetaminophen
Acetaminophen is widely available and useful as a nonprescription analgesic for mild to moderate pain and as an antipyretic. The usual adult dose is 650 mg orally or rectally every 4 hours as needed or 1 g every 6 hours as needed. The suggested maximum daily dose of acetaminophen at the present time is 4 g/day with a lower maximum dose (<2 g/day) for patients taking warfarin. Doses higher than 4 g/day can lead to hepatotoxicity. The combination of an NSAID with acetaminophen provides better analgesia for somatic and visceral pain than either agent alone.
Nonsteroidal Anti-inflammatory Drugs
Multiple NSAIDs are available to treat somatic and visceral pain. These agents do not work well for neuropathic pain. NSAIDs exert their pharmacologic effect by reversibly inhibiting prostaglandin formation through nonselective inhibition of cyclooxygenase enzymes I and II (COX-I and COX-II). Aspirin is the only NSAID that irreversibly binds to COX-I. COX-I is responsible for maintenance of normal physiologic functions (i.e., gastric mucosal barrier, platelet aggregation); COX-II is an inducible enzyme that is found at sites of tissue injury. If NSAIDs are prescribed, it is probably best to give them around-the-clock initially because NSAIDs inhibit a process from occurring: prostaglandin generation → cytokine release → edema, inflammation, and pain.
NSAIDs should not be given to patients after the 30th week of pregnancy, patients with congestive heart failure, or patients with renal dysfunction. Giving an NSAID to a patient who is already receiving a high-dose corticosteroid may lead to more toxicity without improved anti-inflammatory effects.
More recent publications indicate that NSAIDs may inhibit healing of bone fusions and fractures. Randomized controlled trials assessing the effect of NSAID exposure in patients with fractures, fusions, and osteotomies are needed to address these emerging concerns. It seems reasonable that NSAID use be avoided if possible for several months after the original incident or surgery in patients with risk factors for poor bone healing.
Ibuprofen
Ibuprofen is the classic NSAID. It is available as over-the-counter tablets (200 mg), prescription-strength tablets (400 mg, 600 mg, 800 mg), and suspension. The suggested maximum daily dose is 3200 mg divided in three to six doses.
Diclofenac
Diclofenac is one of the most potent NSAIDs and is available only by prescription. It is dosed every 12 hours and is available as 25-mg, 50-mg, and 75-mg tablets. Diclofenac does not seem to interfere with the cardioprotective effects of low-dose aspirin.
Naproxen
Naproxen is available over-the-counter as 220 mg and as prescription-strength 250-mg, 375-mg, and 500-mg tablets. It is usually given every 12 hours with a maximum dose of 1000 mg/day.
Ketorolac
Ketorolac was the first parenteral NSAID available; however, it is not more effective than an equipotent dose of other oral NSAIDs. The dose is 15 to 30 mg intravenously or intramuscularly every 6 hours or 10 mg orally every 6 hours. An intravenous bolus dose can be given over 30 to 60 seconds. The maximum parenteral dose is 120 mg/day, and the maximum oral dose is 40 mg daily. Patients older than 65 years or weighing less than 50 kg should receive a maximum dose of 15 mg every 6 hours. Ketorolac is contraindicated in patients with advanced renal impairment.
Celecoxib
At the present time, celecoxib is the only highly selective COX-II inhibitor on the market. Other COX-II inhibitors were withdrawn from the market owing to a risk of cardiovascular disease. Celecoxib has a slightly lower incidence of gastric and duodenal ulcers compared with nonselective COX inhibitors. The normal dose is 100 to 200 mg daily up to 200 mg every 12 hours. It has no effect on platelet aggregation. Celecoxib is used as part of many preoperative preemptive analgesic regimens for hip and knee replacements owing to its opioid-sparing effect and lack of platelet effects.
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