Objectives
Nonsteroidal anti‐inflammatory drugs (NSAIDs) are the first‐line medication for acute low back pain (LBP). It is unclear if the choice of NSAID impacts outcomes. We compared ibuprofen, ...ketorolac, and diclofenac for the treatment of acute, nonradicular LBP.
Methods
This was a three‐armed, double‐blind, comparative effectiveness study, in which we enrolled patients at the conclusion of an ED visit for musculoskeletal LBP and determined outcomes by telephone 5 days later. Patients were randomized to receive a 5‐day supply of 600 mg of ibuprofen, 10 mg of ketorolac, or 50 mg of diclofenac, each to be used every 8 h as needed. Every participant also received LBP education. The primary outcome was improvement in Roland‐Morris Disability Questionnaire (RMDQ), a 24‐item instrument on which lower scores indicate better LBP functional outcomes, between ED visit and day 5. Secondary outcomes included pain intensity, measured using the descriptors none, mild, moderate, and severe, and the presence of stomach irritation.
Results
A total of 868 patients were screened and 66 patients were enrolled in each of the three arms. Baseline characteristics were similar. Improvements in RMDQ by day 5 were as follows: ibuprofen 9.4, ketorolac 11.9, and diclofenac 10.9 (p = 0.34). Mild or no pain on day 5 was as follows: ibuprofen 38 of 61 (62%), ketorolac 47 of 59 (80%), and diclofenac 45 of 62 (71%; 95% CI for rounded mean difference of 17% between ibuprofen and ketorolac = 1, 33%, p = 0.04, number needed to treat = 6 95% CI = 3–69). Stomach irritation was reported by 16 of 62 (26%) ibuprofen patients versus three of 61 (5%) in the ketorolac arm and six of 64 (9%) in the diclofenac arm (p < 0.01).
Conclusion
There were no important differences between groups with regard to the primary outcome. These data do not rule out that possibility that ketorolac results in better pain relief and less stomach irritation than ibuprofen.
As rates of opioid use disorder in the general population have increased, some have questioned whether IV opioids should be used routinely for treatment of acute severe pain in the emergency ...department (ED).
We determined the incidence of persistent opioid use among opioid-naïve patients exposed to IV opioids in the ED.
This was a prospective observational cohort study conducted in two EDs in the Bronx, NY. Opioid-naïve adults with severe pain who received IV opioids in the ED were followed-up 6 months later by telephone interview and review of the state opioid prescription database. We defined persistent opioid use as filling 6 or more prescriptions for opioids in the 6 months following the ED visit or an average of one prescription per month.
We screened 1555 patients. Of these, 506 patients met entry criteria and provided analyzable data. Morphine was the IV opioid most frequently administered in the ED (478, 94%), followed by hydromorphone (20, 4%). Of the 506, 8 (2%) received both IV morphine and hydromorphone and 63 (12%) participants were prescribed an opioid for use after the ED visit. One patient/506 (0%) met our apriori criteria for persistent opioid use within 6 months.
Among 506 opioid naïve ED patients administered IV opioids for acute severe pain, only one used opioids persistently during the subsequent 6 months.
In US emergency departments (EDs), patients with low back pain are often treated with nonsteroidal anti-inflammatory drugs and muscle relaxants. We compare functional outcomes among patients ...randomized to a 1-week course of naproxen+placebo versus naproxen+orphenadrine or naproxen+methocarbamol.
This was a randomized, double-blind, comparative effectiveness trial conducted in 2 urban EDs. Patients presenting with acute, nontraumatic, nonradicular low back pain were enrolled. The primary outcome was improvement on the Roland-Morris Disability Questionnaire (RMDQ) between ED discharge and 1 week later. All patients were given 14 tablets of naproxen 500 mg, to be used twice a day, as needed for low back pain. Additionally, patients were randomized to receive a 1-week supply of orphenadrine 100 mg, to be used twice a day as needed, methocarbamol 750 mg, to be used as 1 or 2 tablets 3 times per day as needed, or placebo. All patients received a standardized 10-minute low back pain educational session before discharge.
Two hundred forty patients were randomized. Baseline demographic characteristics were comparable. The mean RMDQ score of patients randomized to naproxen+placebo improved by 10.9 points (95% confidence interval CI 8.9 to 12.9). The mean RMDQ score of patients randomized to naproxen+orphenadrine improved by 9.4 points (95% CI 7.4 to 11.5). The mean RMDQ score of patients randomized to naproxen+methocarbamol improved by 8.1 points (95% CI 6.1 to 10.1). None of the between-group differences surpassed our threshold for clinical significance. Adverse events were reported by 17% (95% CI 10% to 28%) of placebo patients, 9% (95% CI 4% to 19%) of orphenadrine patients, and 19% (95% CI 11% to 29%) of methocarbamol patients.
Among ED patients with acute, nontraumatic, nonradicular low back pain, combining naproxen with either orphenadrine or methocarbamol did not improve functional outcomes compared with naproxen+placebo.
Head pain is the fifth most common reason for emergency department (ED) visits. It is second only to focal weakness as the most common reason for neurological consultation in the ED. This manuscript ...reviews how patients with migraine, the most common primary headache disorder for which patients seek medical treatment, are managed in the ED. We discuss existing guidelines for head imaging in patients with migraine, recommended pharmacologic treatments, and current treatment trends. We also review studies evaluating the discharge care of migraine patients in the ED. With the goal of standardizing, streamlining, and optimizing ED‐based migraine care, we offer ideas for future research to improve the evaluation, treatment, and discharge care of patients who present to an ED with acute migraine.
Background
Use of oral opioids does not result in more pain relief than nonopioid alternatives when administered to patients as first‐line treatment for acute musculoskeletal pain. This study ...compared the efficacy of oxycodone/acetaminophen to that of acetaminophen alone as second‐line treatment for patients with acute musculoskeletal pain who were administered prescription‐strength ibuprofen and reported insufficient relief 1 h later.
Methods
A randomized, double‐blind study was conducted in two urban emergency departments. Opioid‐naïve patients ≥ 18 years with an acute musculoskeletal injury were administered ibuprofen 600 mg as part of the study protocol. Those who reported insufficient relief 1 h later were randomized (1:1 ratio) to oxycodone 10 mg/acetaminophen 650 mg or acetaminophen 650 mg. The primary outcome was improvement in 0 to 10 pain scale between randomization and 2 h later. We also assessed medication‐associated adverse events. A sample size calculation, built around a minimum clinically important difference of 1.3 units, determined the need for 154 patients.
Results
We screened 924 patients and enrolled 393. All 393 received ibuprofen. A total of 159 (40%) patients reported inadequate relief after 1 h had elapsed. A total of 154 of these were randomized, 77 to oxycodone/acetaminophen and 77 to acetaminophen. Baseline characteristics were comparable. Among patients randomized to oxycodone/acetaminophen, mean (±SD) improvement in 0 to 10 pain scale was 4.0 (±2.6) versus 2.9 (±2.4) in the acetaminophen arm. The 95% confidence interval (CI) for the mean difference of 1.1 was 0.3 to 1.9. Among patients who received oxycodone/acetaminophen, 26 of 76 (34%) reported any medication‐related adverse event versus seven of 74 (9%) participants who received acetaminophen. The 95% CI for the between‐group difference of 25% was 12% to 37%).
Conclusion
Among patients with acute musculoskeletal pain refractory to oral ibuprofen, oxycodone/acetaminophen resulted in slightly greater pain relief than acetaminophen, but this was associated with more medication‐related adverse events.
To increase the relevance of this extensive literature for emergency physicians, we imposed in our review, in addition to the requirement that patients present with non-chronic, non-radicular low ...back pain, two important stipulations: 1) Chiropractic manipulation needed to be contrasted with an intervention that was clearly of no benefit. While the efficacy/harm ratio of opioids was beyond the scope of our review, we agree that in general, adding an opioid to a non-steroidal anti-inflammatory drug does not improve pain or functional outcomes one week after an ED visit for acute, non-radicular low back pain and does not prevent the transition from acute to chronic low back pain 4. 1 S. Rothberg, B.W. Friedman, Complementary therapies in addition to medication for patients with nonchronic, nonradicular low back pain: a systematic review, Am J Emerg Med, Vol. 35, Iss. 1, 2017, 55-61 2 A. Qaseem, T.J. Wilt, R.M. McLean, M.A. Forciea, Clinical Guidelines Committee of the American College of Physicians, Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians, Ann Intern Med, Vol. 166, Iss. 7, 2017, 514-530 3 B.W. Friedman, M. Chilstrom, P.E. Bijur, E.J. Gallagher, Diagnostic testing and treatment of low back pain in United States emergency departments: a national perspective, Spine, Vol. 35, Iss. 24, 2010, E1406-E1411 4 B.W. Friedman, A.A. Dym, M. Davitt, L. Holden, C. Solorzano, D. Esses, JAMA, Vol. 314, Iss. 15, 2015, 1572-1580 5 B.W. Friedman, S. Gensler, A. Yoon, R. Nerenberg, L. Holden, P.E. Bijur, Predicting three-month functional outcomes after an ED visit for acute low back pain, Am J Emerg Med, Vol. 35, Iss. 2, 2017, 299-305
We investigated clinical risk factors that predict poor 30-day headache outcomes among patients evaluated in the emergency department (ED) for post-traumatic headache (PTH).
This was an analysis of ...data from a randomized, placebo-controlled study of IV metoclopramide + diphenhydramine for acute PTH. Patients were enrolled during an ED visit and received telephone follow-up with a structured questionnaire 30 days later. The primary outcome was frequency of headaches 30 days after ED discharge. We used multivariable logistic regression models to determine which clinical variables were associated with frequent headaches at 30 days.
In total, 160 patients were enrolled in the study. 134 (84%) patients completed the 30-day questionnaire and were included in the analysis, including 90 females and 44 males. 30 patients (22%, 95% CI = 0.16 to 0.30) reported frequent headaches at 30-day follow-up. In the multivariable analysis, female sex (OR = 4.03, 95% CI = 1.23±13.13), patients who blamed themselves for their injury (OR = 0.13, 95% CI = 0.04±0.45), and patients who were unsure if they sustained loss of consciousness during the traumatic incident (OR = 5.63, 95% CI = 1.89±16.78) were found to be associated with poor 30-day outcomes. Medication received in the ED and age were not associated.
More than 1 out of five patients treated in the ED for acute PTH experienced frequent headaches 30 days later. Women and patients who were uncertain as to whether they had experienced loss of consciousness were at increased risk of frequent PTH. Blaming oneself for the head trauma was associated with less frequent PTH.
Objective
Migraine causes more than 1.2 million visits to US emergency departments (EDs) annually. Many of these visits are revisits among patients who had already been treated in an ED for migraine. ...The goal of this analysis was to determine the frequency of headache revisits among patients who present to an ED for management of migraine and sociodemographic factors associated with the revisit.
Methods
Using the New York City Department of Health and Mental Hygiene Syndromic Surveillance database, we conducted a retrospective nested cohort study. We analyzed visits from 18 NYC EDs with discharge diagnoses in the first 6 months of 2015. We conducted descriptive analyses to determine the frequency of headache revisit within 6 months of an index ED visit for migraine and the elapsed time to revisit. Using multivariable logistic regression, we assessed associations between age, sex, poverty, and revisit.
Results
Of 1052 ED visits with an ED discharge diagnosis of migraine during the first 6 months of 2015, 277 (26.3%) had a headache revisit within 6 months of their initial migraine visit and 131 (12.5%) had two or more revisits at the same hospital. Of the revisits for headache, 9% occur within 72 hours and 46% occur within 90 days of the initial migraine visit. Sex, age, and poverty level were not associated with an ED revisit.
Conclusion
More than a quarter of initial ED visits for migraine are followed by headache revisits in <6 months. Future work should target interventions to decrease the frequency of headache revisits.
Background
Parenteral opioids are used in more than 50% of emergency department (ED) visits for migraine. Use of opioids for migraine has been associated with subsequent ED visits, perhaps because of ...opioid‐induced euphoria. In this study, we quantify the extent to which nontherapeutic effects of opioids influence migraine outcomes. We hypothesized that “feeling good” and medication likeability would in fact be associated with receipt of opioids (rather than relief of migraine pain) and that receipt of opioids (rather than relief of migraine pain) would be associated with return visits to the ED.
Methods
During an ED‐based clinical trial, migraine patients were randomized to receive hydromorphone 1 mg or prochlorperazine 10 mg + diphenhydramine 25 mg IV. Thirty minutes after medication administration, we asked, (1) How much did you like the medication you received? and (2) How good did the medication make you feel? Participants were asked to provide answers on a 0‐10 scale. We also determined 0‐10 pain scores at baseline and 1 hour and number of return visits for headache during the subsequent month.
Results
Sixty‐three patients received prochlorperazine and 64 hydromorphone. Prochlorperazine pain scores improved by 6.8 (SD: 2.6), hydromorphone by 4.7 (SD: 3.3) (95%CI for difference of 2.1: 1.0, 3.2). On the 0‐10 likeability scale, prochlorperazine patients reported a mean of 7.2 (SD: 2.8), hydromorphone 6.9 (SD: 2.9) (95% CI for difference of 0.3: −0.7, 1.3). On the 0‐10 feeling good scale, prochlorperazine patients reported a mean of 7.5 (SD: 2.3), hydromorphone 6.8 (SD: 2.8) (95%CI: for difference of 0.7: −0.2, 1.6). In the hydromorphone group, 8/57 (14%, 95%CI: 7, 26%) returned to the ED vs 5/63 (8%, 95%CI: 3,18%) in the prochlorperazine group. In regression modeling, feeling good was independently associated with pain relief (P < .01) but not with medication received (P = .67) or return visits (P = .12). Similarly, medication likeability was independently associated with pain relief (P < .01) but not medication received (P = .12) or return visits (P = .16).
Conclusion
We did not detect an association between hydromorphone and medication likeability, feeling good, or return visits to the ED. Headache relief was associated with medication likeability and feeling good.
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