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==Background==
*The shift in pain management from a symptomatic approach to a mechanistic approach has allowed providers to address pain in a more targeted and efficient manner
*By recognizing the pain receptors that are the culprit behind a patient’s symptoms, a higher level of care can be administered

==Pharmacologic Options==
Below are a series of recommendations outlined by Dr. Sergey Motov and Dr. David Lyness. <ref>*Lyness, D., & Motov, S. (2016, July 7). CERTA Opioid Alternatives and Analgesics. Retrieved July 25, 2016, from http://www.propofology.com/infographs/certa-opioid-alternatives-as-analgesics</ref>

===[[Abdominal Pain]] (Non Traumatic)===
*IV [[Ketorolac]] 10-15 mg or IV [[Diclofenac]] 75 mg or IV [[Metimazole]]
*IV [[Acetaminophen]] 1g over 15 minutes
*IV [[Lidocaine]] 1.5 mg/kg of 2% over 10-15 minutes
*IV [[Ketamine]] 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour

===[[Abdominal Pain]] (Traumatic)===
*IV [[Acetaminophen]] 1g over 15 minutes
*IV [[Ketamine]] 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour

===[[Back Pain]] (Nonradicular)===
*IV [[Ketorolac]] 10-15 mg or [[Ibuprofen]] 400 mg PO or IV [[Diclofenac]] 75 mg or IV [[Metimazole]] 1g
*Trigger point injection 10 ml 0.5% [[Bupivacaine]] or 20 ml of 1% [[Lidocaine]]
*IV [[Acetaminophen]] 1g over 15 minutes
*IV [[Lidocaine]] 1.5 mg/kg of 2% over 10-15 minutes
*IV [[Ketamine]] 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour

===[[Burns]]===
*IV [[Ketamine]] 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour
*IV [[Lidocaine]] 1.5 mg/kg of 2% over 10-15 minutes, + continuous infusion at 1.5-2.5 mg/kg/hour
*IV [[Dexmedetomidine]] 02.-0.7 mcg/kg/hour drip 
*IV [[Clonidine]] 0.3-2 mcg/kg/hour drip

===[[Headache]]===
*IV [[Metoclopramide]] 10 mg (slow drip 10-15 minutes) or IV Prochlorperazine 10 mg (slow infusion) 
*With IV [[Diphenhydramine]] 25-50 mg or IV Chlorpromazine 12.5 mg (slow infusion in 500 ml over 30 min - 1 hour)
*SQ [[Sumatriptan]] 6 mg (within 1 hour of onset, 12 mg 1 hour later)
*IV [[Ketorolac]] 10-15 mg or IV Diclofenac 75 mg or IV Metimazole 1 g
*US Guided nerve block, Paracervical trigger point injections with 2% Lidocaine or 0.5% Bupivacaine 
*IV [[Haloperidol]] 2.5 mg, IV [[Droperidol]] 2-5 mg (slow infusion over 10 min)
*IV [[Propofol]] (intractable migraine) 10 mg IVP q5 minutes
*Refractory cases - [[Ketamine]] 0.2-0.3 mg/kg short infusion

===MSK===
*US guided nerve block
*IV [[Ketorolac]] 10-15 mg or IV Diclofenac 75 mg or IV Metimazole 1 g
*IV [[Acetaminophen]] 1g over 15 minutes
*IV [[Ketamine]] 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour

===Neuropathic Pain===
*IV [[Ketamine]] 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour
*IV [[Lidocaine]] 1.5 mg/kg of 2% over 10-15 minutes, + continuous infusion at 1.5-2.5 mg/kg/hour
*IV [[Dexmedetomidine]] 02.-0.3 mcg/kg/hour IV infusion 
*[[Gabapentin]] (not included in Motov/Lyness regimen)
**Day 1: 300mg PO qDay
**Day 2: 300mg PO q12hr
**Day 3: 300mg PO q8hr

===[[Renal Colic]]===
*IV [[Ketorolac]] 10-15 mg or IV Diclofenac 75 mg or IV Metimazole 1 g
*IV [[Acetaminophen]] 1g over 15 minutes
*IV [[Lidocaine]] 1.5 mg/kg of 2% over 10-15 minutes
*IN [[Desmopressin]] 40 mcg once as adjunct to NSAID’s
*IV [[Ketamine]] 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour

===[[Sickle Cell Crisis]]===
*IN [[Ketamine]] 1 mg/kg (no more than 1 ml per nostril)
*IV [[Ketamine]] 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour and SQ infusion at 0.15-0.25 mg/kg/hour
*IV/IM [[Haloperidol]] or [[Droperidol]] 5-10 mg
*IV [[Dexmedetomidine]] 02.-0.3 mcg/kg/hour continuous infusion

==Benefits==
*The cycle of opioid abuse and addiction often arises with the first time administration of opioids in the ED for a variety of medical complaints. Limiting this exposure is one of the ways providers can help combat this epidemic
*A better understanding of underlying pain mechanisms will also likely result in overall improvement in pain management and satisfaction

==Feasibility==
*A recent study being done at Maimonides hospital designed an 8 hour opioid free ED shift that resulted in over 80% pain satisfaction scores at 30 and 60 minutes and no opioids used during the shift with just one opioid prescription written<ref>The Opioid-Free ED: Coming Soon to a Hospital Near You. Medscape. Feb 28, 2015.</ref> 

Weaknesses:
*During above study, a challenge was managing staff that had little experience in using medications for off label uses. 
*Certain subsets of patients will have various contraindications that will need to be considered such as patients with cardiovascular disease and NSAIDs. Those contraindications will not be reviewed on this page. 

==References==
<references/>

[[Category:Pharmacology]]
[[Category:Palliative Medicine]]