Pain is a common complaint in the emergency department. An alternative to opioids is desirable. Oral medications are not feasible with gastrointestinal disorders or NPO. Intravenous medications require skill and time. Intravenous/intramuscular medications are painful with potential needlestick injury. Intranasal medications have rapid onset, easy administration, do not need skilled providers, and no risk of needlestick injury. A total of 28 adults with acute pain (numeric rating scale ≥ 4) received intranasal ketorolac. Numeric rating scale decreased in all: 32% complete pain relief, median (interquartile range) decrease −5 (−6.8 to −4) (p < .001). Pain relief onset was median [interquartile range] 5 (2.3, 15.0) min. Vital signs remained normal. There were no nasal mucosal changes, no complications. Minor side effects, mostly nasal burning, in 43%, resolved within 5 min. Patients and nurses were satisfied with intranasal ketorolac, and would use it again. Intranasal ketorolac had a rapid onset, was effective, safe, well tolerated with minor side effects that resolved quickly.
BahreiniM.SafaieA.MirfazaelianH.JaliliM. (2020). How much change in pain score does really matter to patients?The American Journal of Emergency Medicine, 38(8), 1641–1646. https://doi.org/10.1016/j.ajem.2019.158489
2.
BenhamouD. (2018). Ketorolac dose-response for acute pain is well known and the safety rules for adequate prescribing are clear. Journal of Clinical Anesthesia, 44, 86. https://doi.org/10.1016/j.jclinane.2017.10.016
3.
BerthelotJ. M.Darrieutort-LafitteC.Le GoffB.MaugarsY. (2015). Strong opioids for noncancer pain due to musculoskeletal diseases: Not more effective than acetaminophen or NSAIDs. Joint Bone Spine, 82(6), 397–401. https://doi.org/10.1016/j.jbspin.2015.08.003
4.
BrownC.MoodieJ.BisleyE.BynumL. (2009). Intranasal ketorolac for postoperative pain: a phase 3, double-blind, randomized study. Pain Medicine, 10(6), 1106–1114. https://doi.org/10.1111/j.1526-4637.2009.00647.x
5.
DaoustR.PaquetJ.CournoyerA.PietteÉ.MorrisJ.LessardJ.CastonguayV.WilliamsonD.ChaunyJ. M. (2020). Side effects from opioids used for acute pain after emergency department discharge. The American Journal of Emergency Medicine, 38(4), 695–701. https://doi.org/10.1016/j.ajem.2019.06.001
6.
DuberH. C.BarataI. A.Cioè-PeñaE.LiangS. Y.KetchamE.Macias-KonstantopoulosW.RyanS. A.StavrosM.WhitesideL. K. (2018). Identification, management, and transition of care for patients with opioid use disorder in the emergency department. Annals of Emergency Medicine, 72(4), 420–431. https://doi.org/10.1016/j.annemergmed.2018.04.007
7.
FarrarJ. T.YoungJ. P.JrLaMoreauxL.WerthJ. L.PooleM. R. (2001). Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain, 94(2), 149–158. https://doi.org/10.1016/S0304-3959(01)00349-9
8.
FeizerfanA.ShehG. (2015). Transition from acute to chronic pain. Continuing education in Anaesthesia. Critical Care & Pain, 15(2) 98–102. https://doi.org/10.1093/bjaceaccp/mku044
9.
GrantG. M.MehlischD. R. (2010). Intranasal ketorolac for pain secondary to third molar impaction surgery: A randomized, double-blind, placebo-controlled trial. Journal of Oral and Maxillofacial Surgery, 68(5), 1025–1031. https://doi.org/10.1016/j.joms.2009.10.023
10.
GroverC. A.CloseR. J.WieleE. D.VillarrealK.GoldmanL. M. (2012). Quantifying drug-seeking behavior: A case control study. The Journal of Emergency Medicine, 42(1), 15–21. https://doi.org/10.1016/j.jemermed.2011.05.065
11.
HattenB. W.CantrillS. V.DublinJ. S.KetchamE. M.RundeD. P.WallS. P.WolfS. J., & American College of Emergency Physicians. (2020). Clinical policy: Critical issues related to opioids in adult patients presenting to the emergency department. Annals of Emergency Medicine, 76(3), e13–e39. https://doi.org/10.1016/j.annemergmed.2020.06.049
12.
HeA.HershE. V. (2012). A review of intranasal ketorolac tromethamine for the short-term management of moderate to moderately severe pain that requires analgesia at the opioid level. Current Medical Research and Opinion, 28(12), 1873–1880. https://doi.org/10.1185/03007995.2012.744302
13.
HookerE. A.MallowP. J.OglesbyM. M. (2019). Characteristics and trends of emergency department visits in the United States (2010–2014). The Journal of Emergency Medicine, 56(3), 344–351. https://doi.org/10.1016/j.jemermed.2018.12.025
14.
KellyA. M. (1998). Does the clinically significant difference in visual analog scale pain scores vary with gender, age, or cause of pain?Academic Emergency Medicine, 5(11), 1086–1090. https://doi.org/10.1111/j.1553-2712.1998.tb02667
KyriacouD. N. (2017). Opioid vs nonopioid acute pain management in the emergency department. Journal of the American Medical Association, 318(17), 1655–1656. https://doi.org/10.1001/jama.2017.16725
18.
Lobaina MatoY. (2019). Nasal route for vaccine and drug delivery: Features and current opportunities. International Journal of Pharmaceutics, 572, 118813. https://doi.org/10.1016/j.ijpharm.2019.118813
19.
LuoF.LiM.FlorenceC. (2021). State-Level economic costs of opioid use disorder and fatal opioid overdose - United States, 2017. Morbidity and Mortality Weekly Report, 70(15), 541–546. https://doi.org/10.15585/mmwr.mm7015a1
20.
MinerJ. R. (2019). Pain management in the emergency department. In BallantyneJ. C.FishmanS. M.RathmellJ. P. (Eds.), Bonica’s management of pain (pp. 1770–1781). Lippincott Williams & Wilkins.
21.
MinnsA. B.ClarkR.F. (2018). Substance abuse. In WallsR. M.HockbergerR. S.Gausche-HillM. (Eds.), Rosen’s emergency medicine: Concepts and clinical practice (9th ed., Vol. 2, pp. 1823–1828.e1). Elsevier.
22.
MoodieJ. E.BrownC. R.BisleyE. J.WeberH. U.BynumL. (2008). The safety and analgesic efficacy of intranasal ketorolac in patients with postoperative pain. Anesthesia and Analgesia, 107(6), 2025–2031. https://doi.org/10.1213/ane.0b013e318188b736
MotovS.YasavolianM.LikourezosA.PushkarI.HossainR.DrapkinJ.CohenV.FilkN.SmithA.HuangF.RockoffB.HomelP.FrommC. (2017). Comparison of intravenous ketorolac at three single-dose regimens for treating acute pain in the emergency department: A randomized controlled trial. Annals of Emergency Medicine, 70(2), 177–184. https://doi.org/10.1016/j.annemergmed.2016.10.014
25.
National Academies of Sciences, Engineering, and Medicine. (2019). In AlperJ.OlchefskeI.GraigL. (Eds.), Pain management for people with serious illness in the context of the opioid use disorder epidemic: Proceedings of a workshop [E-book]. The National Academies Press. https://doi.org/10.17226/25435
PathanS. A.MitraB.CameronP. A. (2018). A systematic review and meta-analysis comparing the efficacy of nonsteroidal anti-inflammatory drugs, opioids, and paracetamol in the treatment of acute renal colic. European Urology, 73(4), 583–595. https://doi.org/10.1016/j.eururo.2017.11.001
28.
PfaffenrathV.FenzlE.BregmanD.FärkkilaM. (2012). Intranasal ketorolac tromethamine (SPRIX(R)) containing 6% of lidocaine (ROX-828) for acute treatment of migraine: Safety and efficacy data from a phase II clinical trial. Cephalalgia: An International Journal of Headache, 32(10), 766–777. https://doi.org/10.1177/0333102412451359
29.
PollackC. V.Jr.DiercksD. B.ThomasS. H.ShapiroN. I.FanikosJ.MaceS. E.RafiqueZ.ToddK. H. (2016). Patient-reported outcomes from a national, prospective, observational study of emergency department acute pain management with an intranasal nonsteroidal anti-inflammatory drug, opioids, or both. Academic Emergency Medicine, 23(3), 331–341. https://doi.org/10.1111/acem.12902
30.
PoulinP. A.NelliJ.TremblayS.SmallR.CaluyongM. B.FreemanJ.RomanowH.StokesY.CarpinoT.CarsonA.ShergillY.StiellI. G.TaljaardM.NathanH.SmythC. E. (2016). Chronic pain in the emergency department: A pilot mixed-methods cross-sectional study examining patient characteristics and reasons for presentations. Pain Research & Management, 2016, 3092391. https://doi.org/10.1155/2016/3092391
31.
PourmandA.JasaniG.ShayC.Mazer-AmirshahiM. (2018). The evolving landscape of acute pain management in the era of the opioid crisis. Current Pain and Headache Reports, 22(11), 73. https://doi.org/10.1007/s11916-018-0728-y
RashJ. A.PoulinP. A.ShergillY.RomanowH.FreemanJ.TaljaardM.HebertG.StiellI. G.SmythC. E. (2018). Chronic pain in the emergency department: A pilot interdisciplinary program demonstrates improvements in disability, psychosocial function, and healthcare utilization. Pain Research & Management, 2018, 1875967. https://doi.org/10.1155/2018/1875967
SinB.WiafeJ.CiaramellaC.ValdezL.MotovS. M. (2018). The use of intranasal analgesia for acute pain control in the emergency department: A literature review. American Journal of Emergency Medicine, 36(2), 310–318. https://doi.org/10.1016/j.ajem.2017.11.043
36.
SinglaN.SinglaS.MinkowitzH. S.MoodieJ.BrownC. (2010). Intranasal ketorolac for acute postoperative pain. Current Medical Research and Opinion, 26(8), 1915–1923. https://doi.org/10.1185/03007995.2010.495564
37.
Sprix ® (Ketorolac Tromethamine) Nasal Spray. (n.d.). SPRIX® Official Site for HCPs. Retrieved June2, 2021, from https://www.sprix.com/hcp-site
38.
TashimaT. (2020). Shortcut approaches to substance delivery into the brain based on intranasal administration using nanodelivery strategies for insulin. Molecules, 25(21), 5188. https://doi.org/10.3390/molecules25215188
TaylorA.BeckerS.SchweinhardtP.CahillC. (2016). Mesolimbic dopamine signaling in acute and chronic pain: implications for motivation, analgesia, and addiction. Pain, 157(6), 1194–1198. https://doi.org/10.1097/j.pain.0000000000000494
ToddK. H.DucharmeJ.ChoiniereM.CrandallC. S.FosnochtD. E.HomelP.TanabeP., & PEMI Study Group .(2007). Pain in the emergency department: Results of the pain and emergency medicine initiative (PEMI) multicenter study. The Journal of Pain, 8(6), 460–466. https://doi.org/10.1016/j.jpain.2006.12.005
43.
ToddK. H.DucharmeJ.ChoiniereM.JohnsonC.CrandallC.PuntilloK. (2004). Pain and pain-related functional interference among discharged emergency department patients. Annals of Emergency Medicine, 44(4), S86. https://doi.org/10.1016/j.annemergmed.2004.07.282
WattsK.BalzerS.DrumM.NussteinJ.ReaderA.FowlerS.BeckM. (2019). Ibuprofen and acetaminophen versus intranasal ketorolac (Sprix) in an untreated endodontic pain model: A randomized, double-blind investigation. Journal of Endodontics, 45(2), 94–98. https://doi.org/10.1016/j.joen.2018.11.005
46.
WongC. K.O’RiellyC. M.TeitgeB. D.SutherlandR. L.FarquharsonS.GhoshM.RobertsonH. L.LangE. (2020). The characteristics and effectiveness of interventions for frequent emergency department utilizing patients with chronic noncancer pain: A systematic review. Academic Emergency Medicine, 27(8), 742–752. https://doi.org/10.1111/acem.13934
47.
YoungA. C.BuvanendranA. (2019). Nonsteroidal anti-inflammatory drugs and acetaminophen. In BallantyneJ. C.FishmanS. M.RathmellJ. P. (Eds.), Bonica’s management of pain (pp. 1315–1332). Lippincott Williams & Wilkins.
48.
ZhuW.ChernewM. E.SherryT. B.MaestasN. (2019). Initial opioid prescriptions among U.S. commercially insured patients, 2012–2017. New England Journal of Medicine, 380(11), 1043–1052. https://doi.org/10.1056/NEJMsa1807069
