Helping relieve patients’ pain is a key component of care in emergency departments, where opioid medications traditionally have been a mainstay of pain management. But opioids can pose risks and side effects, and amid the ongoing opioid epidemic, emergency providers have been looking for alternatives to help patients cope with pain.
Now, a University of Colorado Anschutz Department of Emergency Medicine faculty member is lead author of a new journal review article that offers a playbook for ED clinicians on using a more targeted and potentially less perilous pain-management approach guided by ultrasound imaging. It’s called regional anesthesia, or an ultrasound-guided nerve block.
Emergency medicine pharmacist Lance Ray, PharmD, BCPS, BCEMP, FASHP, is an adjoint instructor in the department who practices at Denver Health. He is a founding member and president-elect of the Academy of Emergency Medicine Pharmacists within the Society for Academic Emergency Medicine, and a fellow of the American Society of Health-System Pharmacists.
His paper, “Regional anesthesia in the emergency department: A review of key pharmacotherapeutic considerations,” was published recently in The American Journal of Emergency Medicine.
Regional anesthesia can be a safe and effective way to reduce opioid use in the ED for many patients, the article says. But that requires knowing which drugs work best in which situations, being careful with dosing and additives, and having a plan ready in case of a rare but serious toxicity reaction.
“Between all the trauma, chest pain, and abdominal pain we see, it’s unavoidable that we turn to opioid medications in the ED,” Ray says. “We do it in very controlled doses, but there are still risks. And with the opioid epidemic in perspective, we try to limit those as much as possible, especially when it comes to discharging a patient with a prescription. So we are big on what we call ALTO — alternatives to opioids.”
The paper is an extension of the key role that emergency medicine pharmacists play in clinical patient care — a role broader than the popular image of a pharmacist working behind a counter filling prescriptions. In fact, Ray says about one in three pharmacists in the United States work at a hospital or clinic rather than at a retail pharmacy.
“In the ED, we’re medication consultants and drawing up the meds a lot of the time, but we’re also clinical partners,” Ray says. “We're at the bedside a lot, developing care plans with the physicians and nurses. We’re there to talk about things like, ‘Is this the right patient for this medication? What are the side effects? How fast should we infuse it?’ And at a teaching hospital, we do a lot of teaching with the residents about medications.”
Pain — trauma, chest pain, and abdominal pain — is a major reason why people come to the ED, with estimates of visits related to some form of pain ranging from 40% to 70% in recent studies.
“At Denver Health, we see so many trauma fractures from scooter accidents,” Ray says. “They hit something, and they flip head over heels.”
Traditionally, ED treatment for pain has often meant opioid drugs. In 2010, among adults ages 18-44, percentages of ED visits for pain in which an opioid was given or prescribed peaked at 49.1%. The rates that year were 44.4% for adults ages 45-64 and 37.7% for adults ages 65 and older. By 2020, those rates had all declined, but they still ranged from 21.3% (ages 18-44) to 26.1% (ages 45-64).
Ray’s paper says that opioids can cause serious problems for patients, ranging from constipation and drowsiness to slowed breathing, physical dependence, and addiction that can become life-threatening. Also, the drugs are usually administered intravenously, often providing higher potency.
Meanwhile, since the late 1990s, legal and illegal opioids have fueled a major public health crisis in the U.S., leading to an estimated 806,000 deaths related to an opioid overdose between 1999 and 2023 — nearly 80,000 in 2023 alone.
Facts like these help explain why, in recent years, regional anesthesia has become more common in EDs as part of a “multimodal pain strategy” — using different medications and approaches to target various pain pathways rather than relying solely on opioids.
Instead of opioid pain medications that usually impact the whole body, regional anesthesia involves numbing a specific nerve or group of nerves near an injury, shutting down sodium channels that the nerves need to fire. Real-time, high-resolution ultrasound imaging of nerves and surrounding tissue allows clinicians to guide needles precisely and inject anesthetics exactly where needed.
In their paper, Ray and his colleagues break down regional anesthesia drugs into two broad categories: amides, such as lidocaine, bupivacaine, and ropivacaine, which currently are non-opioid pain drugs most commonly used in the ED; and esters, like chloroprocaine, that can serve as a shorter-acting alternative, or can be used if a patient has an amide allergy.
The article evaluates how various drugs are best used. Lidocaine, for example, is a fast-acting drug that’s good for quick procedures, like stitching a wound or numbing an injured finger, and wears off in an hour or two. And ropivacaine and bupivacaine take effect more slowly but last several hours, so they’re better for blocking pain from fractures of the hip or ribs.
The paper also covers several add-on ingredients — adjuncts — that can help a pain management drug work better or last longer. A steroid called dexamethasone, for example, can extend numbness by a couple of hours and pain relief by four to seven hours. When injected directly at the site alongside the anesthetic, these medications may limit exposure to the rest of the body, reducing the risk of steroid side effects.
The article offers some cautions. It warns of Local Anesthetic Systemic Toxicity (LAST), a rare but serious situation in which too much anesthetic gets into the bloodstream, usually from an accidental injection in the wrong place or too high a dose, potentially causing seizures or dangerous heart rhythm problems — even cardiac arrest.
In such cases, Ray and his co-authors say EDs should be prepared to administer an intravenous lipid emulsion, a solution that can help mop up the anesthetic circulating in the blood and pull it away from the heart and brain.
As advice for EDs seeking to expand use of regional anesthesia, Ray and his colleagues recommend pre-defined order sets laying out which drugs to use and when. They also call for structured training programs so ED clinicians get proper practice with ultrasound-guided blocks, from needle skills to pharmacology and complication management. And pharmacists should be on hand to help manage drug selection and stocking of rescue treatments, they say.
Ray notes another reason to pivot from an opioids-only approach to a multimodal pain strategy.
“There's a lot of literature that shows that if you focus on opioids rather than multimodal, you increase length of stay in the ED and you create more complications,” he says. “Length of stay is such a big metric that we focus on, since we’re so busy and we're trying to turn over patients while still providing the best care. If we can decrease average patient stays by not using opioids as much, that's huge for the health care system, and it’s huge for the patients in the waiting room.”
Matthew Riscinti, MD, BS, an assistant professor at CU Anschutz Emergency Medicine, was a co-author of the article.