Today I am joined by a good friend Sergey Motov, MD. Sergey is an EM doc with a particular interest in pain management in the ED. Sergey recently, as part of a approved study, ran an entire ED shift without a single administration of an opioid for pain. Can it be done?

The Pain-Free ED

Sergey has an amazing site, with resources and lectures: The Pain-Free ED

The Concept and Rationale of an Opioid-Free ED: Why do we need alternative to opioids in the ED?

No consensus on optimum opioid doses (weight-based, fixed, nurse initiated?)

* http://www.ncbi.nlm.nih.gov/pubmed/24210367

* http://www.ncbi.nlm.nih.gov/pubmed/23264318

* http://www.ncbi.nlm.nih.gov/pubmed/20825766

* http://www.ncbi.nlm.nih.gov/pubmed/16898939

Poor titration practices

* http://www.ncbi.nlm.nih.gov/pubmed/21908134

* http://www.ncbi.nlm.nih.gov/pubmed/20825766

Overdosing hydromorphone/ under-dosing morphine

* http://www.ncbi.nlm.nih.gov/pubmed/16898939

* http://www.ncbi.nlm.nih.gov/pubmed/19426295

Severe side effects ( especially geriatric patients)

* http://www.ncbi.nlm.nih.gov/pubmed/24033733

* http://www.ncbi.nlm.nih.gov/pubmed/24629443

Begetting Addiction

Regulatory concerns of prescribing opioids.

Concept of Multimodal Receptor/Channel Targeted Analgesia (RCTA)

Cox Inhibition

COX 1-2 - NSAIDS ( renal colic, back pain; by honoring “Analgesic Ceiling” concept)

COX 2 -Cox 3 - Acetaminophen (as well as TRPV1( capsaicin receprots) , cannabis, endogenous opioids)

* http://shortcoatsinem.blogspot.com/2012/03/iv-acetaminophen-all-rage.html

* http://www.anesthesiologynews.com/download/SR122_WM.pdf

* http://emj.bmj.com/content/early/2011/02/28/emj.2010.104687

* http://www.beat-journal.com/BEATJournal/index.php/BEAT/article/view/45

* http://www.ncbi.nlm.nih.gov/pubmed/25197573

* http://www.ncbi.nlm.nih.gov/pubmed/24381620

* http://www.ncbi.nlm.nih.gov/pubmed/22186009

NMDA antagonism- ketamine ( IV push, drip, continuous infusion as adjunct to opioids or single agents)

* http://www.ncbi.nlm.nih.gov/pubmed/25197290

* http://www.ncbi.nlm.nih.gov/pubmed/23602757

* http://www.ncbi.nlm.nih.gov/pubmed/23159425