Pain is the most common complaint among patients who present to the emergency department (ED).¹ In 2017, the American College of Emergency Physicians (ACEP) released its policy statement on how to optimize the treatment of acute pain in the ED, which recommends starting with nonopioid medications given orally, or by intravenous injection if not tolerated orally.² Ibuprofen and ketorolac, non-steroidal anti-inflammatory drugs (NSAIDs), and acetaminophen are three nonopioid medications frequently given for acute pain management in the ED and are available in oral, IV, and intramuscular routes. To minimize the potential harms associated with opioid use, ACEP recommends opioid analgesics only in cases where nonopioid or nonpharmaceutical interventions are insufficient at managing pain and only after educating the patient on potential side effects or risk of opioid use disorder.²

To investigate whether the policy statement or the COVID pandemic correlated with changes in pain management prescribing in the ED, we studied the proportion of ED encounters for pain-related chief complaints that included a medication administration of acetaminophen, ibuprofen, ketorolac, or a parenteral or oral opioid from 2014 to 2023.

We found that the proportion of pain-related ED encounters that included a parenteral opioid administration decreased after the publication of ACEP’s recommendation from 23.6% of encounters in July 2017 to 21.6% in May 2018. That rate increased slightly but remained steady until the COVID-19 pandemic in March 2020 led to an increase in the acuity of patients who were presenting to the ED.³ In April 2020, the rate of encounters with a parenteral opioid administration was 22.6%, and that rate remained higher than pre-pandemic levels at 26.4% of pain-related ED encounters in December 2023.

The rate of pain-related ED encounters with an oral opioid administration, including opioid combination medications, decreased prior to the ACEP’s policy statement in 2017 and after the release of the statement. The rate of encounters with an oral opioid administration has remained steady since 2020.

Ibuprofen administrations occurred for around 8% of ED encounters from 2014 to the start of the COVID-19 pandemic and then dropped to 6.4% of encounters in April 2020, concurrent with early concerns about NSAIDs and COVID-19.⁴ The percentage of encounters with ibuprofen administrations has increased slightly since that initial pandemic drop, but it remains lower than pre-pandemic levels at 7.5% of encounters in December 2023.

Acetaminophen and ketorolac administrations have increased since 2017, and rates of administrations dropped only slightly for these two types of pain medications at the start of the pandemic. Rates of encounters with acetaminophen and ketorolac administrations quickly returned to pre-pandemic rates in late 2020 and continued to gradually increase to 15.3% and 16.5% of ED encounters respectively in December 2023.

A sensitivity analysis limiting to only ED encounters that resulted in hospital admissions showed similar rates of medication administrations across all medication types studied.

While nonopioid medication administrations have increased since the ACEP’s policy statement in 2017, parenteral opioid administrations continue to be the most commonly administered pain medication for pain-related ED encounters. Ongoing monitoring of trends in ED administration of pain medications is warranted to evaluate ED clinical practice and the effort to balance effective pain management with patient and population concerns.

Original Publication Date: March 1, 2024
Last Updated: March 14, 2024

These data come from Cosmos, a collaboration of Epic health systems representing more than 238 million patient records from 1,345 hospitals and more than 28,000 clinics from all 50 states and Lebanon. This study was completed by two teams that worked independently, each composed of a clinician and research scientists. The two teams came to similar conclusions. This study was done in collaboration with researchers from NYU Langone Health. Graphics by AJ Hinkens.

References

1. Downey LV, Zun LS. Pain management in the emergency department and its relationship to patient satisfaction. J Emerg Trauma Shock. 2010;3(4):326-330. doi:10.4103/0974-2700.70749
2. American College of Emergency Physicians. Policy Statement: Optimizing the Treatment of Acute Pain in the Emergency Department. Published April 2017. optimizing-the-treatment-of-acute-pain-in-the-ed.pdf (acep.org). Accessed February 28, 2024.
3. Alban C, Barkley E, Cox C. Sicker Patients, More Admissions: How COVID-19 has Changed Emergency Care. Epic Research. https://epicresearch.org/articles/sicker-patients-more-admissions-how-covid-19-has-changed-emergency-care. Accessed on February 14, 2024.
4. World Health Organization. The use of non-steroidal anti-inflammatory drugs (NSAIDS) in patients with COVID-19. Published April 2020. The use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients with COVID-19 (who.int). Accessed February 28, 2024.