CONTINUING MEDICAL EDUCATION IN ACADEMIC EMERGENCY MEDICINE CME Information: Are Nonpharmacologic Pain Interventions Effective at Reducing Pain in Adult Patients Visiting the Emergency Department? A Systematic Review and Meta-analysis

Objectives: Pain is a common complaint in the emergency department (ED). Its management currently depends heavily on pharmacologic treatment, but evidence suggests that nonpharmacologic interventions may be beneficial. The purpose of this systematic review and meta-analysis was to assess whether nonpharmacologic interventions in the ED are effective in reducing pain. Methods: We conducted a systematic review of the literature on all types of nonpharmacologic interventions in the ED with pain reduction as an outcome. We performed a qualitative summary of all studies meeting inclusion criteria and meta-analysis of randomized controlled studies measuring postintervention changes in pain. Interventions were divided by type into five categories for more focused subanalyses. Results: Fifty-six studies met inclusion criteria for summary analysis. The most studied interventions were acupuncture (10 studies) and physical therapy (six studies). The type of pain most studied was musculoskeletal pain (34 studies). Most (42 studies) reported at least one improved outcome after intervention. Of these, 23 studies reported significantly reduced pain compared to control, 24 studies showed no difference, and nine studies had no control group. Meta-analysis included 22 qualifying randomized controlled trials and had a global standardized mean difference of –0.46 (95% confidence interval = –0.66 to –0.27) in favor of nonpharmacologic interventions for reducing pain. Conclusion: Nonpharmacologic interventions are often effective in reducing pain in the ED. However, most existing studies are small, warranting further investigation into their use for optimizing ED pain management. P ain is a common symptom of patients in the emergency department (ED) and presents challenges for effective and efficient management. In clinical practice, pain is most commonly subjectively quantified by the patient, thus making it difficult to create evidencebased and standardized treatment guidelines. Therefore, oligoanalgesia or the inadequate treatment of pain has been shown to be a major problem in the From the Duke University School of Medicine (JTS, HBW, SAE); the Division of Emergency Medicine, Duke University Hospital (JRNV, SAE); the Department of Neurosurgery, Duke Global Neurosurgery and Neurology Division (JRNV); and the Duke Global Health Institute (JRNV), Durham, NC. Received January 17, 2018; revision received March 8, 2018; accepted March 8, 2018. JTS and HBW contributed equally to the manuscript. The authors have no relevant financial information or potential conflicts to disclose. Author contributions: Drs. Sakamoto, Ward, Vissoci, and Eucker all contributed to the design, analysis, interpretation, and writing of the manuscript. All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. PROSPERO Database Registration: CRD42015029671. Supervising Editor: Kennon J. Heard,MD, PhD. Address for correspondence and reprints: Stephanie Eucker; e-mail: stephanie.eucker@duke.edu. ACADEMIC EMERGENCY MEDICINE 2018;25:940–957. 940 ISSN 1553-2712 © 2018 by the Society for Academic Emergency Medicine doi: 10.1111/acem.13411 ED in multiple observational studies. Inadequate treatment of acute pain may increase the risk of patients developing chronic pain, further perpetuating the current pain epidemic in the United States. Currently, treatment of pain in the ED and upon discharge consists mainly of pharmacologic interventions such as nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and opioids. While pharmacologic treatments have been shown to be effective in reducing pain, each carries a risk of potentially serious side effects, including renal, cardiac, and gastrointestinal toxicity in the case of NSAIDs; liver toxicity with acetaminophen; and respiratory depression and the risk for abuse disorders and overdose with opioids. From 2001 to 2010, opioid prescription rates in the ED substantially increased with a concomitant rise in opioid use disorders and overdose related deaths. For this reason, recent guidelines published by the Centers for Disease Control and Prevention regarding the treatment of chronic pain recommend the use of nonopioid therapy unless benefits regarding pain and function with opioid therapy outweigh risks of opioid use disorder and overdose. However, these guidelines do not address acute pain, and they recommend in-depth patient discussions regarding goal setting and risk management perhaps not feasible in the ED setting. Therefore, the decision to prescribe opioids for pain management upon discharge from the ED is challenging and imprecise as clinicians must weigh the consequences of oligoanalgesia with the risks of overdose and use disorders based on limited, subjective patient data. To reduce this burden and improve pain relief, the incorporation of effective adjunctive methods for managing pain in the ED is key. The wealth of literature on chronic pain has established a biopsychosocial model for understanding mechanisms of chronic pain and highlights the need for comprehensive treatment incorporating multiple therapeutic modalities for effective pain management. According to the biopsychosocial model, pain is an experience that stems from the complex and dynamic interplay between an individual’s physiological, psychological, and social factors. Based on this model, numerous studies have demonstrated that the most effective treatments in chronic pain consist of combining nonpharmacologic interventions, such as physical therapy, acupuncture, and cognitive behavioral therapy, with pharmacologic treatments. Increasing evidence suggests that a similar biopsychosocial interplay determines the patient experience of acute pain. Recent recommendations developed by the American College of Emergency Physicians and the American Academy of Emergency Medicine suggest the importance of improving pain management and reducing opioid use by incorporating nonpharmacologic interventions, but the strength of this recommendation has been dampened by a lack of supporting systematic evidence. Hence, a critical need exists for identifying effective nonpharmacologic interventions and integrating these into acute pain management strategies. While numerous reviews exist discussing nonpharmacologic management for pain in the outpatient chronic pain, postsurgical, and pediatric settings, there are currently no published reviews investigating nonpharmacologic pain management initiated in the ED. Therefore, this review aims to identify all studies that examine the use of nonpharmacologic interventions for pain management among adults presenting to the ED, to assess what strategies have been attempted and/or implemented, and to assess the efficacy on pain reduction of nonpharmacologic interventions initiated in the ED. We hypothesize that nonpharmacologic interventions will demonstrate an overall effective pain reduction in adult patients presenting to the ED.