Challenges in Pain Management Research

Date: October 29, 2024 Reference: Galili et al. Low dose ketamine as an adjunct to morphine: a randomized controlled trial among patients with and without current opioid use. AEM Oct 2024. Guest Skeptic: Dr. Neil Dasgupta is an emergency medicine physician and ED intensivist from Long Island, NY.  He is the Vice Chair of the Emergency Department and Program Director of the EM residency program at Nassau University Medical Center in East Meadow, NY, the safety net hospital for Nassau County. Case: You are hitting the zone in your shift, a veritable disposition machine meeting the constant flow of patients through the emergency department (ED). As you finish a note on a complex critically ill patient, you hear howls of pain coming from the EMS triage desk.  A 38-year-old male patient in cycling gear is being brought in after colliding with a lamp post with an obvious upper extremity deformity.  He explains loudly to the triage nurse that he has chronic back pain from multiple prior cycling accidents, and regularly takes significant doses of extended-release oxycodone.  As you walk over to assess the patient, you take note of how distressed he is and consider how to get him comfortable enough to work him up in the ED. Background:  Management of acute pain is an important activity of emergency physicians and can be challenging. Patients frequently come to the ED because they are in pain, and our ability to relieve that pain is central to the patient experience.  Alternatives to opiate pain medications have significant limitations with analgesic ceilings (NSAIDs) as well as side effects or toxicity potential that limit their use and efficacy. This issue is even more fraught with difficulty in a patient who chronically uses opioid medications and has developed a tolerance. Within the House of Medicine, there has been a significant shift in the use of opioids as we are more fully understanding the patient consequences and societal effects of a previously more liberal pain management strategy.  Judicious use of medications became paramount, with physicians becoming wary of the over-aggressive treatment of acute pain, leaving many patients hurting and frustrated.  One effective strategy is a multi-modal approach to pain management, including using adjuvant non-opioid medications for better pain control while attempting to minimize the dose of opiates. Enter ketamine. Ketamine is a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist that was most used as a dissociative anesthetic. It provides excellent sedation, analgesia and amnesia while having a favourable hemodynamic profile and preserving airway reflexes.  It has become a favourite medication in emergency departments for procedural sedation as well as a useful behavioural takedown medication.  More recently, sub-dissociative doses of ketamine have been used to treat acute pain. We have covered the use of ketamine multiple times on the SGEM, and there will be a list of those episodes at the end of this podcast. The most recent episode was SGEM#457 looking at nebulized ketamine. Clinical Question: Is ketamine an effective adjunct agent along with morphine for acute pain control in the ED? Reference: Galili et al. Low dose ketamine as an adjunct to morphine: a randomized controlled trial among patients with and without current opioid use. AEM Oct 2024. Population: Patients over 18 years old in a single center in Denmark presenting to the ED with acute pain rated ≥5 on a numeric rating scale (NRS) from 0–10 that the ED physician decided required intravenous opioids. Intervention: Administration of low-dose ketamine (LDK) 0.1 mg/kg intravenous (IV) bolus in addition to morphine IV dosed by clinical practice guidelines and adjusted if the patient is currently on opioid medication. Comparison: Administration of isotonic saline as placebo with morphine Outcome: Primary Outcome: Pain reduction as measured by patient-reported pain...