Acceptability, Adaptation, and Clinical Outcomes of Acupuncture Provided in the Emergency Department: A Retrospective Pilot Study

Clinician views on acupuncture for acute pain care in a busy urban emergency department

INTRODUCTION

Opioid misuse and dependence remain critical public health issues in the U.S., contributing significantly to reduced life expectancy. Emergency departments (EDs) are key settings for implementing opioid reduction strategies when treating acute pain, such as nonpharmacologic treatment options like acupuncture. This study explored clinician-related factors influencing the integration of the Pain Elimination through Acupuncture Research and Learning (PEARL) program for pain reduction within a high-volume urban ED.

METHODS

This study employed a sequential mixed methods design, involving surveys and interviews with ED clinicians. An 11-item electronic survey was administered annually to assess clinician attitudes related to appropriateness and effectiveness of integrating acupuncture into the ED's comprehensive care plan for treatment of pain. Near the end of the 3rd year of the PEARL program, semi-structured interviews were conducted to gather in-depth insights into clinician knowledge and perceptions of the program.

RESULTS

Quantitative survey data from 99 eligible ED clinicians indicated positive perceptions of the program's appropriateness and effectiveness, and improved understanding of acupuncture referral procedures. Analysis of qualitative interviews conducted with 16 ED clinicians revealed five key themes: acupuncture as an acceptable analgesic strategy to reduce the use of opioids, patient benefits, program presence in the ED, integration challenges, and the need for continued education.

CONCLUSION

Strong acceptance of acupuncture as a feasible nonpharmacologic addition to the comprehensive pain care plan used in the ED was observed. Dedicated space, expanded acupuncture staff and hours, and ongoing training of ED staff will require institutional support to sustain acupuncture as a nonpharmacologic treatment option for ED patients.

Participant experiences receiving acupuncture for acute musculoskeletal pain in an emergency department: A qualitative evaluation

OBJECTIVE

Acupuncture is an evidence-based pain treatment in clinic settings, but its optimal delivery has not been established in emergency departments (EDs). As part of an adaptive pragmatic randomized controlled trial of ED acupuncture for acute musculoskeletal pain (NCT04290741), we embedded a qualitative evaluation of acupuncture treatment acceptability and suggestions for improvement from study participants receiving acupuncture in the ED.

METHODS

Semi-structured interviews conducted remotely evaluated factors impacting patients' perspectives, willingness to participate in, and experiences with ED acupuncture. The codebook was iteratively developed, and recruitment and analysis continued until information saturation was reached.

RESULTS

Twenty-eight participants receiving ED acupuncture between February 2020-March 2021 were interviewed, with median age 44 years, 46.4% female, and 61% having never previously received acupuncture. Overall, ED patients with acute musculoskeletal pain expressed interest in acupuncture and reported an overall positive experience. Most reported acupuncture met their expectations for pain improvement, and many reported additional improvements in stress, anxiety, and sleep quality. Participants with a positive experience were more likely to recommend acupuncture to others. Key positive aspects included open communication with compassionate and knowledgeable acupuncturists. Participants found the ED setting acceptable and convenient for receiving acupuncture. Furthermore, participants provided actionable feedback like addressing fear of needles to improve the ED acupuncture experience.

CONCLUSIONS

In conclusion, ED patients with acute musculoskeletal pain were interested in and had positive experiences with acupuncture treatment for pain and found the ED setting acceptable and convenient. Participant feedback can be used to improve acupuncture treatment in the ED.

Acupuncture in the emergency department (ACUITY): Results from a BraveNet multi-center feasibility randomized controlled trial

Background

Pain plays a significant role in emergency department (ED) visits, however safe and effective nonpharmacologic options are needed. Prior studies of acupuncture in the ED reported pain reduction with minimal side effects, but most were small and single site.

Methods

We conducted ACUITY, a prospectively designed multi-center feasibility RCT. Our goal was to recruit 165 adults with acute non-emergent pain ≥4 on a 0-10-point scale at three EDs affiliated with BraveNet Practice Based Research Network. At baseline and 45-60 min later (post), participants self-assessed their pain and anxiety using a 0-10 rating scale. The primary feasibility outcome was recruitment of participants, whereas secondary outcomes were retention, and participant/provider acceptability.

Results

From May 3, 2021, to September 24, 2022, 632 eligible individuals were approached and 165 enrolled (165/632: 26.1 %), meeting our recruitment goal. Notably, 42.4 % of enrollees were Black/African American, 42.4 % were White/Caucasian, and 13.9 % were Hispanic/Latino. Participants were randomized to Acupuncture (n = 83) or Usual care (n = 82), of which 151 (91.5 %) and 128 (77.6 %) provided pain and anxiety scores at post-treatment and 1-week respectively. Acupuncture was rated acceptable to participants and providers. Mean pain ratings (pre-to-post) were 7.4 (2.2) to 4.8 (2.8) for acupuncture and 7.1 (2.3) to 6.4 (2.5) for usual care. Mean anxiety ratings (pre-to-post) were 4.5 (3.4) to 2.5 (2.6) for acupuncture and 4.1 (3.4) to 3.5 (3.2) for usual care.

Conclusion

Successful completion of ACUITY indicates we have the expertise and preliminary data to conduct a future definitive, multi-center RCT.

Trial registration Clinical trialsgov

NCT04880733.

An Adaptive Pragmatic Randomized Controlled Trial of Emergency Department Acupuncture for Acute Musculoskeletal Pain Management

STUDY OBJECTIVE

Acute musculoskeletal pain in emergency department (ED) patients is frequently severe and challenging to treat with medications alone. The purpose of this study was to determine the feasibility, acceptability, and effectiveness of adding ED acupuncture to treat acute episodes of musculoskeletal pain in the neck, back, and extremities.

METHODS

In this pragmatic 2-stage adaptive open-label randomized clinical trial, Stage 1 identified whether auricular acupuncture (AA; based on the battlefield acupuncture protocol) or peripheral acupuncture (PA; needles in head, neck, and extremities only), when added to usual care was more feasible, acceptable, and efficacious in the ED. Stage 2 assessed effectiveness of the selected acupuncture intervention(s) on pain reduction compared to usual care only (UC). Licensed acupuncturists delivered AA and PA. They saw and evaluated but did not deliver acupuncture to the UC group as an attention control. All participants received UC from blinded ED providers. Primary outcome was 1-hour change in 11-point pain numeric rating scale.

RESULTS

Stage 1 interim analysis found both acupuncture styles similar, so Stage 2 continued all 3 treatment arms. Among 236 participants randomized, demographics and baseline pain were comparable across groups. When compared to UC alone, reduction in pain was 1.6 (95% confidence interval [CI]: 0.7 to 2.6) points greater for AA+UC and 1.2 (95% CI: 0.3 to 2.1) points greater for PA+UC patients. Participants in both treatment arms reported high satisfaction with acupuncture.

CONCLUSION

ED acupuncture is feasible and acceptable and can reduce acute musculoskeletal pain better than UC alone.

Acupuncture is a feasible alternative to procedural sedation for shoulder reduction in the emergency department

Treating shoulder dislocations is common in the emergency department and often requires procedural sedation. The use of acupuncture for treatment of chronic pain has been shown to be successful in various outpatient settings, and some EDs have recently incorporated acupuncture as an analgesia adjunct for chronic painful conditions to avoid opioid therapy. Limited data describe acupuncture to facilitate ED procedures. Here we present two cases of acute shoulder dislocation that were successfully treated with acupuncture as an alternative to parenteral pharmacologic procedural sedation. A 50 year old male sustained an anterior shoulder dislocation after an altercation, and a 59 year old female sustained an anterior dislocation after a fall. Instead of using conventional pharmacologic sedation and analgesia during shoulder reduction, both were treated with acupuncture in the ED. Reduction in both cases was rapid, safe, and avoided use of any parenteral medications, procedural sedation monitoring, or prolonged nurse observation. Using acupuncture as alternative to opioids for ED procedures deserves future study for orthopedic and other common ED procedures.

Retrospective Outcomes of a New Acupuncture Service at a Comprehensive Cancer Center

Introduction: Among cancer centers, patients' interest in acupuncture is growing, in addition to clinical research in the intervention. Their National Cancer Institute-designated comprehensive cancer center piloted an acupuncture service. Their aim was to assess whether acupuncture impacted patient self-reported symptoms as delivered clinically and discuss their implementation strategy. Methods: Patients undergoing acupuncture at a comprehensive cancer center from June 2019 to March 2020 were asked to complete a modified Edmonton Symptom Assessment Scale (ESAS) before and after each session. The authors evaluated symptom changes after acupuncture in both outpatient and inpatient settings. A change of ≥1 U, on the 0-10 scale, was considered clinically significant. Results: Three hundred and nine outpatient and 394 inpatient acupuncture sessions were provided to patients at the comprehensive cancer center during this period, of which surveys from 186 outpatient (34 patients) and 124 inpatient (57 patients) sessions were available for analysis. The highest pretreatment symptoms reported by outpatients were neuropathy (5.78), pain (5.58), and tiredness (5.59). Outpatients receiving acupuncture reported clinically significant improvements in pain (ESAS score change of -2.97), neuropathy (-2.68), decreased lack of well-being (-2.60), tiredness (-1.85), nausea (-1.83), anxiety (-1.56), activities of daily living issues (-1.32), depression (-1.23), anorexia (-1.19), insomnia (-1.14), and shortness of breath (-1.14). The most severe pretreatment symptoms reported by inpatients were pain (6.90), insomnia (6.16), and constipation (5.44). Inpatients receiving acupuncture reported clinically significant improvements in anxiety (-3.69), nausea (-3.61), insomnia (-3.26), depression (-2.98), pain (-2.77), neuropathy (-2.68), anorexia (-2.20), constipation (-1.95), and diarrhea (-1.26). Conclusion: Both outpatient and inpatient participants in this pilot acupuncture program reported clinically significant improvements in symptoms after a single acupuncture treatment. Some differences between the outpatient and inpatient settings warrant further investigation.

Electroacupuncture for Pain Outcomes in a Trauma Center's Acute Pain Service: A Retrospective Observational Study

Background

Evidence for acupuncture to treat pain is growing. Electrostimulation of acupuncture needles (electroacupuncture) is common for pain and is thought to augment the therapeutic effect.

Objectives

To examine the association of pain outcomes after a single acupuncture session with electrostimulation included (EA) compared with no electrostimulation included (NEA).

Methods

A retrospective observational study was conducted using electronic health records of acupuncture sessions for adults with acute pain under the care of an acute pain service. Paired t-test and linear regression were used to report pain intensity changes after a single acupuncture session and by including EA. Ordered logistic regression was used to report categorical pain relief. Logistic regression was used to explore the odds of adding EA and the patient's age, gender, and pretreatment pain.

Results

From July 24, 2017, through November 9, 2020, 465 acupuncture sessions recorded EA (n = 194), or NEA (n = 271). Acupuncture, independent of EA status, reduced pain intensity by a mean 2.5 points. EA was associated with a mean 0.38-point reduction in pain intensity more than NEA (confidence interval [95% CI]: -0.75 to -0.01). Among sessions reporting categorical pain relief (n = 415), higher relief was more likely with EA (odds ratio = 2.16, 95% CI: 1.52-3.08). There was no association between EA and the patient's age, gender, and pretreatment pain intensity.

Conclusions

After a single acupuncture session, both EA and NEA reduced pain intensity. Higher categorical pain relief was reported with EA, though the clinical meaning is uncertain. Future research should focus on well-defined populations for electroacupuncture and factors for including electrostimulation.

Adult pain and anticipatory anxiety assessment in the emergency department: An integrative literature review

INTRODUCTION

Patients presenting to the emergency departments in pain often experience co-occurring symptoms. Anticipatory anxiety in the emergency department may be currently under-recognised. Clinical tools to facilitate the assessment of co-occurring symptoms aligns with providing more patient centred care and improved outcomes and experience.

AIMS

This integrative review aimed to identify and examine the psychometric properties of tools currently used for pain and anticipatory anxiety assessment in adult patients presenting to the emergency department. This study also aimed to identify the current clinical practice used to assess adult pain and anticipatory anxiety.

METHODS

Whittemore and Knafl's methodology guided the review process, and it is reported according to relevant items from PRISMA checklist. Studies were included if they focused on tools for pain or anxiety assessment of adults in emergency departments in English language publications since 2010. Quality of studies was evaluated using the Mixed Methods Appraisal Tool (MMAT). The results were summarised through narrative synthesis.

RESULTS

A total of 15 studies were identified for narrative synthesis. Six tools for pain, and four tools for anticipative anxiety were found. All currently used clinical tools assess symptoms in isolation. There was limited discussion of the clinical context of identified tools within the included studies.

CONCLUSION

Pain and anxiety assessment are currently performed in symptom isolation with a variety of tools with varying degrees of reliability. There exists a lack of clinical tools able to assess co-occurring symptoms of pain and anticipatory anxiety in the clinical setting of the emergency department. No studies discussed clinical tool use in current practice.

RELEVANCE TO CLINICAL PRACTICE

The reconstruction of available pain and anxiety assessment tools into one validated and holistic tool for assessment in the ED clinical setting, would provide a contextually appropriate guide to clinical assessment and treatment. Acknowledging and measuring these symptoms may facilitate future rigorous testing of experimental studies of novel methods to reduce pain and anxiety in the ED.

NO PATIENT OR PUBLIC CONTRIBUTION

Patient or public contribution does not apply to this Integrative Review.

CLINICAL TRIAL REGISTRATION NUMBER

Not applicable.

Acupuncture intervention for acute pain in the Emergency Department trial: a consensus process

PURPOSE

This document describes the consensus process and intervention for a National Institutes of Health (NIH)-funded multi-site feasibility study utilizing acupuncture for ACUte paIn in The EmergencY Department (ACUITY). The acupuncture intervention is designed to be flexible and responsive to the most common Emergency Department (ED) scenarios, including trauma, acute pain of the low back, abdomen and/or musculoskeletal system, renal colic and headache.

BACKGROUND

Opioids remain a primary treatment for acute ED pain with attendant risk of adverse effects, addiction liability, diversion and death. Effective/safer options for acute pain are needed. Although acupuncture therapy has shown promise for acute pain in the ED alone or in conjunction with usual care, pragmatic trials are needed to obtain definitive and generalizable evidence.

METHODS

An Acupuncture Advisory Panel was convened that included nine acupuncture experts with 5-44 years of experience in practice and 2-16 years of experience in the acute pain care setting. A modified Delphi process was used with provision of a literature review, surveys of our panel members, three online discussions and email discussion as needed. The STandards for Reporting Interventions in Controlled Trials (STRICTA) checklist was used as a guide.

RESULTS

A responsive acupuncture intervention was agreed on for ACUITY. Session forms were fashioned in REDCap (Research Electronic Data Capture program to capture essential treatment data, assess fidelity and inform our design for a future pragmatic multi-site randomized controlled trial (RCT) of acupuncture in the ED, and for use by other future researchers.

CONCLUSION

Development of a responsive manualization intervention provides the appropriate framework for conducting a future, pragmatic, multi-site, definitive RCT of acupuncture in the ED.

TRIAL REGISTRATION NUMBER

NCT04880733 (ClinicalTrials.gov).

Guidelines for Reasonable and Appropriate Care in the Emergency Department 2 (GRACE-2): Low-risk, recurrent abdominal pain in the emergency department

This second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-2) from the Society for Academic Emergency Medicine is on the topic "low-risk, recurrent abdominal pain in the emergency department." The multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding four priority questions for adult emergency department patients with low-risk, recurrent, undifferentiated abdominal pain. The intended population includes adults with multiple similar presentations of abdominal signs and symptoms recurring over a period of months or years. The panel reached the following recommendations: (1) if a prior negative computed tomography of the abdomen and pelvis (CTAP) has been performed within 12 months, there is insufficient evidence to accurately identify populations in whom repeat CTAP imaging can be safely avoided or routinely recommended; (2) if CTAP with IV contrast is negative, we suggest against ultrasound unless there is concern for pelvic or biliary pathology; (3) we suggest that screening for depression and/or anxiety may be performed during the ED evaluation; and (4) we suggest an opioid-minimizing strategy for pain control. EXECUTIVE SUMMARY: The GRACE-2 writing group developed clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the emergency department (ED). Four patient-intervention-comparison-outcome-time (PICOT) questions were developed by consensus of the writing group, who performed a systematic review of the literature and then synthesized direct and indirect evidence to formulate recommendations, following GRADE methodology. The writing group found that despite the commonality and relevance of these questions in emergency care, the quantity and quality of evidence were very limited, and even fundamental definitions of the population and outcomes of interest are lacking. Future research opportunities include developing precise and clinically relevant definitions of low-risk, recurrent, undifferentiated abdominal pain and determining the scope of the existing populations in terms of annual national ED visits for this complaint, costs of care, and patient and provider preferences.

Acupuncture therapy as an Evidence-Based Nonpharmacologic Strategy for Comprehensive Acute Pain Care: the Academic Consortium Pain Task Force White Paper Update

Background

A crisis in pain management persists, as does the epidemic of opioid overdose deaths, addiction, and diversion. Pain medicine is meeting these challenges by returning to its origins: the Bonica model of multidisciplinary pain care. The 2018 Academic Consortium White Paper detailed the historical context and magnitude of the pain crisis and the evidence base for nonpharmacologic strategies. More than 50% of chronic opioid use begins in the acute pain care setting. Acupuncture may be able to reduce this risk.

Objective

This article updates the evidence base for acupuncture therapy for acute pain with a review of systematic reviews and meta-analyses on postsurgical/perioperative pain with opioid sparing and acute nonsurgical/trauma pain, including acute pain in the emergency department.

Methods

To update reviews cited in the 2018 White Paper, electronic searches were conducted in PubMed, MEDLINE, CINAHL, and the Cochrane Central Register of Controlled Trials for “acupuncture” and “acupuncture therapy” and “acute pain,” “surgery,” “peri-operative,” “trauma,” “emergency department,” “urgent care,” “review(s) ,” “systematic review,” “meta-analysis,” with additional manual review of titles, links, and reference lists.

Results

There are 22 systematic reviews, 17 with meta-analyses of acupuncture in acute pain settings, and a review for acute pain in the intensive care unit. There are additional studies of acupuncture in acute pain settings.

Conclusion

The majority of reviews found acupuncture therapy to be an efficacious strategy for acute pain, with potential to avoid or reduce opioid reliance. Future multicenter trials are needed to clarify the dosage and generalizability of acupuncture for acute pain in the emergency department. With an extremely low risk profile, acupuncture therapy is an important strategy in comprehensive acute pain care.

Acupuncture in the emergency department for pain management: A BraveNet multi-center feasibility study

PURPOSE

Pain accounts for up to 78% of emergency department (ED) patient visits and opioids remain a primary method of treatment despite risks of addiction and adverse effects. While prior acupuncture studies are promising as an alternative opioid-sparing approach to pain reduction, successful conduct of a multi-center pilot study is needed to prepare for a future definitive randomized control trial (RCT).

METHODS

Acupuncture in the Emergency Department for Pain Management (ACUITY) is funded by the National Center for Complementary and Integrative Health. The objectives are to: conduct a multi-center feasibility RCT, examine feasibility of data collection, develop/deploy a manualized acupuncture intervention and assess feasibility/implementation (barrier/facilitators) in 3 EDs affiliated with the BraveNet Practice Based Research Network.Adults presenting to a recruiting ED with acute non-emergent pain (e.g., musculoskeletal, back, pelvic, noncardiac chest, abdominal, flank or head) of ≥4 on a 0-10-point Numeric Rating Scale will be eligible. ED participants (n = 165) will be equally randomized to Acupuncture or Usual Care.At pre-, post-, and discharge time-points, patients will self-assess pain and anxiety using the Numeric Rating Scale. Pain, anxiety, post-ED opioid use and adverse events will be assessed at 1 and 4 weeks. Opioid utilization in the ED and discharge prescriptions will be extracted from patients' electronic medical records.Acupuncture recipients will asked to participate in a brief qualitative interview about 3 weeks after their discharge. ED providers and staff will also be interviewed about their general perspectives/experiences related to acupuncture in the ED and implementation of acupuncture in ACUITY.

RESULTS

Recruitment began on 5/3/21. As of 12/7/21: 84 patients have enrolled, the responsive acupuncture intervention has been developed and deployed, and 26 qualitative interviews have been conducted.

CONCLUSION

Successful conduct of ACUITY will provide the necessary framework for conducting a future, multi-center, definitive RCT of acupuncture in the ED.

CLINICAL TRIALSGOV

NCT04880733 https://clinicaltrials.gov/ct2/show/NCT04880733.

Hydroxyzine for lowering patient's anxiety during prehospital morphine analgesia: A prospective randomized double blind study

STUDY OBJECTIVE

Hydroxyzine is an antihistamine drug used for symptomatic relief of anxiety and tension. We hypothesized that managing the anxiety of patients with severe pain by adding hydroxyzine to a conventional intravenous morphine titration would relieve their pain more effectively.

METHODS

This was a randomized, double-blind, controlled group study of prehospital patients with acute pain scored greater than or equal to 6 on a 0-10 verbal numeric rating scale (NRS). Patients'anxiety was measured with the self-reported Face Anxiety Scale (FAS) ranking from 0 to 4. The percentage of patients with pain relief (NRS score ≤ 3) 15 min after the first injection was the primary outcome.

RESULTS

One hundred forty patients were enrolled. Fifty-one percent (95% CI 39% to 63%) of hydroxyzine patients versus 52% (95% CI 40% to 64%) of placebo patients reported a pain numeric rating scale score of 3 or lower at 15 min. Ninety-one percent (95% CI 83% to 98%) of patients receiving hydroxyzine reported no more severe anxiety versus 78% (95% CI 68% to 88%) of patients with placebo (p > 0.05). Adverse events were minor, with no difference between groups (6% in hydroxyzine patients and 14% in placebo patients).

CONCLUSION

Addition of hydroxyzine to morphine in the prehospital setting did not reduce pain or anxiety in patients with acute severe pain and therefore is not indicated based on our results.

Moving toward patient-centered care in the emergency department: Patient-reported expectations, definitions of success, and importance of improvement in pain-related outcomes

OBJECTIVES

Musculoskeletal pain is a common emergency department (ED) presentation, and patient-centered care may improve quality of life, treatment satisfaction, and outcomes. Our objective was to investigate the expectations, definitions of success, and priorities of ED patients with musculoskeletal pain.

METHODS

We conducted a cross-sectional survey of the demographic, clinical, and psychosocial characteristics of adult ED patients (n = 210) with musculoskeletal pain. Patients completed the Patient-Centered Outcomes Questionnaire to quantify usual, desired, expected, and successful levels of pain and interference with daily activities, fatigue, and emotion from 0 (none) to 100 (worst imaginable). They also reported the importance of improvement in each domain. Cluster analysis identified subgroups by importance ratings. Patients were asked their willingness to try various pharmacologic and nonpharmacologic treatments. Fully completed surveys were analyzed (n = 174).

RESULTS

Most patients desired 100% resolution in each domain and defined treatment success as substantial (median = 63.2%-76.5%) reductions but expected only moderate (median = 45%-53.7%) improvements across all domains. Patients with previous pain episodes had similar desired levels but less stringent definitions of success and expectations for improvement. Cluster analysis identified three patient subgroups by importance ratings of each domain: (1) multiple domains important (n = 118) with high importance attached to all four domains, (2) pain and function important (n = 34) with high importance primarily for pain and interference with daily activities, and (3) only pain important (n = 22). Regardless of subgroup, there was a high willingness to use a variety of pharmacologic and nonpharmacologic treatments.

DISCUSSION

ED patients with musculoskeletal pain have expectations and goals that include addressing impairments in function, improving quality of life, and reducing pain.

CONCLUSIONS

Our findings indicate that: (1) patient subgroups by outcome priorities may exist that could inform multimodal, personalized approaches from the ED and (2) patients are flexible in which treatments they are willing to try to meet their individual goals.

Acupuncture as a Nonpharmacologic Treatment for Pain in a Pediatric Emergency Department

OBJECTIVES

With epidemic opioid deaths and abuse in the United States, government agencies recommend nonpharmacological treatments for pain. However nonopioid treatment options for moderate to severe pain in the pediatric emergency department (PED) are limited. Acupuncture has been shown to be effective for pain. The objective of this study was to evaluate the feasibility of using traditional acupuncture (TA) and battlefield acupuncture (BFA) in the treatment of pain in the PED.

METHODS

A pediatric cohort treated with acupuncture for pain in an urban PED was assessed. All subjects received TA or BFA as treatment, and pre/postacupuncture pain scores, feedback, and adverse events were assessed. The primary outcome was a change in pain score.

RESULTS

Twelve patients received BFA, and 13 received TA for these pain conditions: headaches, sciatica, paraphimosis, torticollis, joint pains (knee, shoulder, jaw), sprains (foot, wrist, thumb), dysmenorrhea, otitis externa, sickle cell, and muscle knot. The mean ± SD pain score change, 5.8 ± 2.5 (P < 0.05; 95% confidence interval, 4.9-7.0), was clinically and statistically significant. Over 90% of subjects reported significant improvement or resolution of pain; 96% were satisfied with pain relief and would receive acupuncture again. Two adverse events were noted: one patient reported dizziness, and another, a tinge of blood at 1 of 90 needled points.

CONCLUSIONS

This study suggests that acupuncture is a potential nonpharmacologic therapeutic option for acute pain management in the PED.

Patient-Reported outcomes of pain care research in the adult emergency department: A scoping review

Despite more than 30 years of research, pain in the emergency department (ED) setting is frequently undertreated. EDs prioritise process measures that often have tenuous links to patient-reported outcomes. However, process measures, such as time to the administration of first analgesic medication, are neither direct objective measures of analgesia nor appropriate surrogate markers of pain relief. Since pain is a subjective symptom that lacks an objective measure, pain research in any clinical environment, including EDs, should rely upon patient-reported outcomes. This scoping review examined patient-reported outcomes (PROs) and patient-reported outcome measures (PROMs) of pain care in the adult emergency department at the micro, meso and macro-level over the last ten years. We reviewed pain care research conducted on adults in EDs over the last ten years and identified 57 articles using 14 patient-reported outcomes of pain care falling into five broad areas, most without validation or adaption to the ED setting. Despite efforts made to incorporate PROs and PROMs into acute pain care research in the ED over the last ten years, there is still no gold-standard PROM in widespread use. We recommend the adaptation of existing tools with rigorous validation in ED populations.

The Intersection of Dissemination Research and Acupuncture: Applications for Chronic Low Back Pain

Dissemination research is the study of distributing information and intervention materials to a specific clinical practice or public health audience. Acupuncture, a healthcare practice involving the stimulation of certain body points, often with thin needles, is considered an evidence-based treatment for low back pain (LBP), but is underutilized in the United States.

Body: We will use the example of acupuncture for LBP to identify opportunities to leverage dissemination research to increase utilization of acupuncture. Deficits in the awareness or knowledge of acupuncture may limit its adoption by patients and other stakeholders. Thus, we summarize methods to gather data on stakeholder awareness and knowledge of acupuncture for LBP, i.e., audience research. Engaging multiple stakeholder audiences (e.g., health system leaders, primary care providers, patients), is needed to generate knowledge on promising dissemination strategies for each audience. Audience segmentation is important for identifying population subgroups for whom adoption of acupuncture may require a more intensive or tailored dissemination strategy. To illustrate potential audience ‘segments’, our research discussion focused on developing dissemination strategies by age (i.e., older adults – those age 65 years or older, and younger adults – those under age 65 ). This decision was prompted by Medicare’s recent policy covering acupuncture for chronic LBP. We leverage current knowledge of barriers and facilitators of acupuncture use to discuss how further tailoring of dissemination strategies might optimize adoption of acupuncture in both groups of adults. Experimental study designs could then be used to compare the effectiveness of such strategies to increase awareness, knowledge, or adoption of acupuncture.

Conclusions: Conducting dissemination research may improve awareness and knowledge of acupuncture, and ultimately the adoption of acupuncture in biomedical settings. We anticipate that the concepts highlighted in this manuscript will also be helpful for those disseminating information about other complementary and integrative health approaches.

Acceptability and Feasibility of Perioperative Music Listening: A Rapid Qualitative Inquiry Approach

Perioperative music decreases pain, anxiety, and analgesia requirements while increasing patient satisfaction. We investigated the acceptability of perioperative music at a women's and children's hospital in Singapore, seeking to uncover barriers and facilitators to implementation in routine practice over a 12-week period. We used an undergraduate-led Rapid Qualitative Inquiry approach that includes data collection from multiple sources, iterative analysis, and additional data collection when necessary. Participants consisted of anesthesiologists and nurses working in the preoperative area, operating room, and postoperative recovery areas. In Stage 1, nurses and anesthesiologists answered a survey assessing attitudes and knowledge about perioperative music and attended a presentation introducing the intervention. In Stage 2, the results of the Stage 1 survey were disclosed, and nurses and anesthesiologists completed a second survey (Stage 1 survey questions with an additional query about implementation). Twenty-nine nurses were interviewed with semi-structured questions on barriers and facilitators to implementation. In Stage 3, nurses retook the Stage 2 survey after one month of implementation. The implementation of perioperative music was both acceptable and feasible in Singapore. The nurses' and anesthesiologists' acceptability increased over time with mostly positive qualitative feedback. Implementation barriers, including patient interest, timing of patient turnover, and added staff workload, appeared minor and could potentially be overcome by utilizing the intervention in the preoperative instead of postoperative area, deploying music in operating rooms with slower turnover, and evenly distributing staff workload. Local implementation stakeholders may make additional recommendations for scaling-up perioperative music interventions to fit other workflows while improving the patient experience.

Utilization of Acupuncture Services in the Emergency Department Setting: A Quality Improvement Study

Purpose

Patients often present to the emergency department (ED) for pain. As opioid fatalities rise, alternative treatments are warranted for pain management. Acupuncture, a nonpharmacological treatment involving the insertion of needles into skin or tissue at specific points within the body, may help to decrease acute pain. Our study aimed to assess the utilization and impact of acupuncture in the ED for acute pain management.

Methods

We conducted a retrospective analysis of purposefully collected quality improvement data. Patients who were ≥18 years old and who presented to the ED at an urban medical center in Wisconsin during 2017 were offered acupuncture services based on their emergency severity index (ESI; range: highest severity [1] - lowest severity [5]), reason for visit, and physician approval. Paired t-tests were used to examine mean differences between pre- and post-acupuncture pain, stress, anxiety, and nausea scores (range: none [0] - worst [10]). Multivariable regression models also were constructed.

Results

A total of 379 patients received acupuncture. Patients presented predominately with an ESI score of 3 (68.9%) or 4 (24.8%); 46.4% received opioids in the ED. Mean pre- and post-acupuncture pain scores significantly differed (6.5 vs 3.4; P<0.001); receiving opioids during the ED visit was not associated with improved pain scores (P=0.948). Stress (5.7 vs 1.9), anxiety (4.8 vs 1.6), and nausea (1.6 vs 0.6) scores also improved (P<0.001) following acupuncture.

Conclusions

Emergency department acupuncture significantly decreased pain, stress, anxiety, and nausea. Our findings support a larger randomized controlled trial to further assesses the impact of acupuncture for acute pain in other ED settings.

Acupuncture Resolves Persistent Pain and Neuroinflammation in a Mouse Model of Chronic Overlapping Pain Conditions

Patients with chronic overlapping pain conditions have decreased levels of catechol-O-methyltransferase (COMT), an enzyme that metabolizes catecholamines. Consistent with clinical syndromes, we previously demonstrated that COMT inhibition in rodents produces persistent pain and heightened immune responses. Here, we sought to determine the efficacy of manual acupuncture in resolving persistent pain and neuroinflammation in the classic inbred C57BL/6 strain and the rapid-wound healing MRL/MpJ strain. Mice received subcutaneous osmotic minipumps to deliver the COMT inhibitor OR486 or vehicle for 13 days. On day 7 after pump implantation, acupuncture was performed at the Zusanli (ST36) point or a non-acupoint for 6 consecutive days. Behavioral responses to mechanical stimuli were measured throughout the experiment. Immunohistochemical analysis of spinal phosphorylated p38 mitogen-activated protein kinase, a marker of inflammation, and glial fibrillary acidic protein, a marker of astrogliosis, was performed on day 13. Results demonstrated that ST36, but not sham, acupuncture resolved mechanical hypersensitivity and reduced OR486-dependent increases in phosphorylated p38 and glial fibrillary acidic protein in both strains. The magnitude of the analgesic response was greater in MRL/MpJ mice. These findings indicate acupuncture as an effective treatment for persistent pain linked to abnormalities in catecholamine signaling and, furthermore, that analgesic efficacy may be influenced by genetic differences. PERSPECTIVE: Chronic overlapping pain conditions remain ineffectively managed by conventional pharmacotherapies. Here, we demonstrate that acupuncture alleviates persistent pain and neuroinflammation linked to heightened catecholaminergic tone. Mice with superior healing capacity exhibit greater analgesic efficacy. Findings indicate acupuncture as an effective treatment for chronic overlapping pain conditions and provide insight into treatment response variability.

Acupuncture for chronic pain: an update and critical overview

PURPOSE OF REVIEW

Acupuncture is now recommended for several chronic pain conditions. Despite supportive evidence of its effectiveness, this ancient approach is often misunderstood, and may still be underused in mainstream practice. A critical review on its effectiveness and practice integration, and mechanisms of action is essential to the medical community that is continuing to seek nonopioid therapies for chronic pain.

RECENT FINDINGS

Mounting evidence supports the effectiveness of acupuncture to treat chronic low back, neck, shoulder, and knee pain, as well as headaches. Additional data are emerging that support the use of acupuncture as an adjunct or alternative to opioids, and in perioperative settings. Findings related to its mechanisms of action include transient receptor potential cation channel vanilloid 1 activation in the periphery, microglial suppression in the cerebral cortex and spinal cord, and regulation of cytokines and other key inflammatory factors in the spinal cord. Incremental integration of acupuncture into pain medicine practices and training programmes continues to grow.

SUMMARY

Acupuncture is effective, safe, and cost-effective for treating several chronic pain conditions when performed by well-trained healthcare professionals. Further studies on its use as an adjunct or alternative to opioids, and in perioperative settings are needed.

Acupuncture in the emergency department: a systematic review of randomised controlled trials

INTRODUCTION

A comprehensive review of both English and Chinese language literature to inform acupuncture practice in emergency department (ED) settings is lacking. Accordingly, we aimed to conduct a systematic review of English and Chinese randomised controlled trials (RCTs) of acupuncture use in the ED.

METHODS

Four English databases (Embase, PubMed, AMED and CENTRAL) and two Chinese databases (CNKI and Wanfang) were systematically searched using the keywords 'acupuncture' and 'emergency department', followed by a bibliographic search of references. The data were extracted and assessed by two independent authors. RCTs were selected based on pre-defined criteria. Data were extracted and a risk of bias assessment was performed using the Cochrane risk of bias tool. The quality of evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

RESULTS

In total, 1461 articles were screened and six RCTs involving 651 patients were included. For various acute pain conditions, acupuncture was superior to sham acupuncture, more effective than intravenous morphine, comparable to conventional ED treatment, and superior to standard ED care alone when used on an adjuvant basis; however, the overall level of evidence was low. Studies that applied acupuncture in hypertension and cardiac arrest were deemed to be at high risk of bias, and the level of evidence for these outcomes was very low. No major adverse events were reported in the included studies.

CONCLUSION

There is a lack of high-quality evidence to support the use of acupuncture in the ED. Multicentre RCTs with rigorous designs are warranted.

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.

Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper

Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.

Acupuncture versus titrated morphine in acute renal colic: a randomized controlled trial

Objective

The objective of this study was to compare the analgesic effect and tolerance profile of acupuncture versus intravenous (IV) titrated morphine in patients presenting to the emergency department (ED) with renal colic.

Materials and methods

A total of 115 patients were randomized into two groups. Patients in the IV titrated-morphine group (n=61) received 0.1 mg/kg morphine every 5 minutes until pain score dropped by at least 50% of its baseline value. Patients in the acupuncture group (n=54) received an acupuncture session of 30 minutes following a prespecified protocol. The visual analog scale (VAS) was used to assess pain intensity at baseline and at 10, 20, 30, 45, and 60 minutes following the start of the treatment protocol. Possible treatment side effects were also recorded.

Results

No significant differences were found between the two groups concerning age, sex, or baseline VAS score. From the 10th minute until the end of the intervention, acupuncture was associated with a deeper analgesic effect than titrated morphine (P<0.05 from the 10th minute and over). Analgesia was also faster in the acupuncture group, with time to obtain 50% reduction of baseline VAS of 14 minutes in the acupuncture group versus 28 minutes in the IV titrated-morphine group (P<0.001). Only three patients in the acupuncture group experienced minor side effects versus 42 in the morphine group (P<0.001). No major side effects were observed in this study.

Conclusion

In ED patients with renal colic, acupuncture was associated with a much faster and deeper analgesic effect and a better tolerance profile in comparison with titrated IV morphine.

Leading the Way to Solutions to the Opioid Epidemic: AOA Critical Issues

BACKGROUND

In the past 2 decades, overdoses and deaths from prescription opioids have reached epidemic proportions in the United States. The widespread use of opioids complicates management of the orthopaedic surgery patient in the acute and chronic settings. Orthopaedic surgeons are some of the top prescribers of opioids in the complex setting of chronic use, abuse, and diversion.

METHODS

The literature regarding the basic science of pharmacologic options for pain management (e.g., opioids and nonsteroidal anti-inflammatory drugs), the impact of strategies on bone and soft-tissue healing, and pain relief are summarized as they relate to the management of orthopaedic injuries and conditions. Additionally, a section on designing solutions to address the current opioid crisis is presented.

RESULTS

The mechanism of action of different classes of analgesic medications is discussed, as well as the basic scientific evidence regarding the impact of narcotic and nonnarcotic analgesic medications on bone-healing and on other organ systems. Differences between pain and nociception, various treatment strategies, and clinical comparisons of the effectiveness of various analgesics compared with opioids are summarized. Finally, options for addressing the opioid crisis, including the description of a large system-wide intervention to impact prescriber behavior at the point of care using health-information solutions, are presented.

CONCLUSIONS

Orthopaedic leaders, armed with information and strategies, can help lead the way to solutions to the opioid epidemic in their respective communities, institutions, and subspecialty societies. Through leadership and education, orthopaedic surgeons can help shape the solution for this critical public health issue.