Acute Pain in the ED: Shifting Paradigms and Emerging Therapies

Management of acute pain is one of the most commonly encountered clinical issues in the emergency department (ED), with an estimated 40% to 70% of patients presenting with acute pain as one of their symptoms of concern.1,2 Despite its frequency, acute pain has historically been undertreated, challenged by the complexities of patient-specific clinical situations and limited advancement in assessment and drug therapy options. Current research is shedding light on how to solve long-standing impediments to effective pain management in the ED, and is discovering new drug therapies with unique mechanisms of action—an encouraging development in an area of medicine long constrained by less-than-ideal options for pharmacological management. Challenges to Managing Pain in the ED Environment The importance of treating acute pain is well-known, as timely treatment can help alleviate patient distress, decrease burden on the health care system by avoiding bounce-back visits to the ED, and prevent progression to chronic pain and potentially chronic pain syndrome. Despite the known advantages of timely and appropriate treatment, the management of acute pain is an ongoing dilemma for health care professionals (HCPs). Professor Fiona Sampson, Director of the Centre for Urgent and Emergency Care Research at the Sheffield Centre for Health and Related Research, leads research on obstacles to effective pain management in the ED. She states, “Our research has identified a number of barriers to pain management, including structural, environmental, and individual. ED processes center around patient flow and pain management is not considered a core priority, often being overlooked when other work takes priority.” Delays in acknowledgment and assessment of pain, provision of initial analgesia, and pain reassessment, as well as unresolved pain at discharge, are all challenges to achieving desirable patient outcomes for pain control in the ED.3 Literature from Europe, Canada, and the United States has found that up to three quarters of patients presenting with acute pain are discharged from the ED still experiencing moderate to severe pain.4 Along with patient flow pressures and competing urgent priorities, the multitude of complexities related to an individual patient's situation can be difficult for HCPs to manage in the fast-paced environment of the ED. The pain patients present with may be related to trauma, secondary to a specific disease state such as sickle cell disease or a palliative condition, or connected to a lack of out-patient pain support in the community. Patients may also be poor historians or fearful of the adverse effects of certain drug therapies, such as constipation or dependence on opioids. Add in the fact that these are often one-off encounters between the HCP and patient, with limited context or therapeutic relationship, and navigating the management of the patient's pain becomes quite complex. Guidelines for the management of acute pain recommend rapid assessment of pain, timely administration of analgesia, regular reassessment, and reduction in pain symptoms.5 How can guideline-directed medical therapy be optimized while working within the ED environment? Reducing Barriers to Analgesia Through Nurse-Initiated Analgesia Luke Burgess, a nurse researcher at the School of Nursing, Queensland University of Technology, led the IMPAINED study, which examined how to achieve impactful and sustainable changes that improve patient outcomes related to pain in the ED.6 Burgess et al found that understanding the local context of the institution's workflows and workloads, and working within these when implementing change, brings about a better chance of success than introducing changes that cause significant disruption. “It's up to the local clinicians to determine what is the correct fit for them and their practice environment. Using implementation science or quality improvement techniques is an easy way to assess this. But for any approaches to be successfully implemented, they need to fit the local practice context well,” Burgess said. One intervention discussed in the IMPAINED study is a multidisciplinary approach to care and empowering nurses to provide nurse-initiated analgesia (NIA) at triage. Burgess notes, “The evidence to support the use of nurse-initiated analgesia is overwhelming, in that it is very effective in improving time-to-analgesia, overall provision of analgesia, and pain levels. It is also safe and well-accepted by both clinicians and patients.” As part of their review on pain management interventions, Professor Sampson et al also examined NIA and found that it decreased the length of time to analgesia administration.7 “By providing some level of pain management at triage, interruptions for pain management are reduced on the shop floor and patients are started on the analgesic ladder. Medical review can then focus on adjusting the analgesia, if necessary,” said Professor Sampson. NIA is typically implemented as part of a larger institutional intervention that streamlines pain management protocols through medical directives for nurse-prescribed acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and codeine or morphine, and uses standardized scales such as the Visual Analog Scale for pain assessment. Coupling protocols with the benefits of NIA can not only improve efficiencies, but also the experience of both the patient and the ED team. Are Pain Scales a Solution to Standardizing Pain Assessment? The use of pain scales organizes the management of pain in the ED by providing HCPs with a quantifiable way to assess pain. The use of these scales has been shown to increase the documentation of pain, and the Visual Analog Scale, Numerical Rating Scale, FACES, COMFORT, and CRIES scales are integrated into the practice of many institutions and ED clinicians.3,5 Despite their popularity and advantages, the use of pain scales is not without controversy. Professor Sampson explained, “Incorporating pain scales in ED pain assessment protocols may improve the likelihood of patients being asked about their pain, but conversely, may not always lead to improved pain management or access to analgesia.” The use of scales relies on the patient's ability to communicate their pain, which could be impeded by emotional distress, language barriers, cognitive impairment, or age. “Patients often struggle to ascribe a number to their pain when in the ED, which leads ED staff to reassess the patient-reported score, often documenting their own interpretation of the score. This makes it difficult to assess whether pain has reduced at a later point, particularly when patients are managed by different clinicians,” Professor Sampson said. This disconnect between the patient and HCP perceptions of the patient's pain can contribute to unresolved pain when the patient is discharged from the ED. While a useful tool in the standardized assessment of pain, in practice, pain scales have been found to be only one part of the ideal approach to acute pain management in the ED, which involves a multipronged strategy that takes into account the patient's clinical situation and ability to communicate their needs, along with in-house standardized practices that account for localized needs and workflows and utilize medical directives to enable NIA. New Approaches to Drug Therapy Assessment and initial analgesia are the first steps in treating acute pain in the ED; next comes the plan to treat the pain. Traditionally, the World Health Organization's pain relief ladder has been used by clinicians and institutions to guide their approach to acute pain management.5 While this ladder was originally intended for the management of cancer-related pain, the ladder provides a straightforward way for HCPs to approach acute pain management in the ED. The ladder recommends starting with non-opioid therapies, providing regular dosing and analgesia, and titrating up and adding additional therapies as needed. The ladder approach is limited by the lack of innovation in novel oral pain medications over the years, with NSAIDs, acetaminophen, and opioids remaining the fundamental oral options for acute pain management. While NSAIDs and opioids are effective for the treatment of acute pain, neither are desirable options for ongoing treatment, due to potential adverse effects such as increased bleeding risks and dependence, respectively. Advances in adjuvant treatments, such as serotonin and norepinephrine reuptake inhibitors, gabapentinoids, and cannabinoids, provide additional options, but do not fill the void of new therapies for acute pain. This presents a clinical conundrum at discharge, as prescribers are hesitant to provide longer-term prescriptions for drug therapies that they cannot monitor. Fortunately, more options for acute pain management are starting to come to the market, offering a completely new mechanism of action and way to approach the treatment of acute pain. In January 2025, the US Food and Drug Administration approved suzetrigine, a selective inhibitor of the Nav1.8 voltage-gated sodium channels.8,9 Suzetrigine works on the peripheral nervous system, including the dorsal root ganglion, where Nav1.8 is located, by inhibiting the transmission of pain signals to the brain. With perceptible onset of pain relief within approximately 35 minutes of the first dose, the approval of suzetrigine marks a significant advancement in alternatives to NSAIDs and opioids for treatment of acute pain, and may lead to the development of similar therapies targeting Nav1.8 and related sodium channels, including Nav1.7 and Nav1.9. The recommended starting dose of suzetrigine is 100 mg orally, followed by 50 mg every 12 hours, with 14 days being the maximum duration of therapy that has been studied.9 Priced at $15.50 per 50 mg dose, seven days of therapy totals approximately $240, making it more expensive than most existing oral therapies for acute pain.10 Because suzetrigine is newly approved, its place in therapy, as well as the ability of patients to access and navigate the cost of this therapy, will be clarified as it begins to be used in the real world and similar therapies potentially become available. Future Opportunities Treating acute pain in the ED is a complex clinical problem, particularly considering the multitude of competing priorities HCPs are required to navigate. The root cause of acute pain is significantly varied, as are patients' abilities to communicate their symptoms and medical histories. Creating a standardized approach to pain assessment and ensuring initial analgesia at triage using a multimodal approach including NIA and targeted use of pain scales can help set patients up for success. Novel oral, non-opioid treatment options, such as suzetrigine, also have the potential to improve the patient experience as they prepare for discharge from the ED and begin managing their pain at home. As real-world experience with these strategies continues to accumulate, ongoing study and evaluation will be essential to align these innovations and new therapies with the challenges of treating acute pain in the ED. SARAH SNOBELEN is a clinical pharmacist and freelance writer and editor. She specializes in writing continuing education content for health care professionals.

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