backpain_pc_400_clr_2144The emergency department (ED) manages acute pain on a daily basis, ranging from non-traumatic back pain to traumatic fractures. Some providers jump immediately to opioids without considering other non-opioid alternatives or start at incorrect doses. In the age of the opioid epidemic (ALiEM-Annals of EM journal club; bookclub discussing Dreamland) and medication errors, choosing the initial right agent(s) and dose(s) are important. Dr. Nick Koch and Dr. Sergey Motov (@PainFreeED) from Maimonides Medical Center present a thoughtful, evidence-based PV reference card on selecting and dosing initial pain medications for ED patients. Also congratulations to Dr. Motov and his team for their recent 2015 Annals of EM publication1 on subdissociative dose ketamine for analgesia.

PV Card: Initial Pain Medication Options

Adapted from 1–14


  1. Motov S, Rockoff B, Cohen V, et al. Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2015;66(3):222-229.e1. [PubMed]
  2. Bartfield J, Flint R, McErlean M, Broderick J. Nebulized fentanyl for relief of abdominal pain. Acad Emerg Med. 2003;10(3):215-218. [PubMed]
  3. Borland M, Jacobs I, King B, O’Brien D. A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the emergency department. Ann Emerg Med. 2007;49(3):335-340. [PubMed]
  4. Galinski M, Dolveck F, Combes X, et al. Management of severe acute pain in emergency settings: ketamine reduces morphine consumption. Am J Emerg Med. 2007;25(4):385-390. [PubMed]
  5. Friedman B, Esses D, Solorzano C, et al. A randomized controlled trial of prochlorperazine versus metoclopramide for treatment of acute migraine. Ann Emerg Med. 2008;52(4):399-406. [PubMed]
  6. Lvovschi V, Aubrun F, Bonnet P, et al. Intravenous morphine titration to treat severe pain in the ED. Am J Emerg Med. 2008;26(6):676-682. [PubMed]
  7. Chang A, Bijur P, Campbell C, Murphy M, Gallagher E. Safety and efficacy of rapid titration using 1mg doses of intravenous hydromorphone in emergency department patients with acute severe pain: the “1+1” protocol. Ann Emerg Med. 2009;54(2):221-225. [PubMed]
  8. Kostic M, Gutierrez F, Rieg T, Moore T, Gendron R. A prospective, randomized trial of intravenous prochlorperazine versus subcutaneous sumatriptan in acute migraine therapy in the emergency department. Ann Emerg Med. 2010;56(1):1-6. [PubMed]
  9. Patanwala A, Keim S, Erstad B. Intravenous opioids for severe acute pain in the emergency department. Ann Pharmacother. 2010;44(11):1800-1809. [PubMed]
  10. Leong L, Kelly A. Are butyrophenones effective for the treatment of primary headache in the emergency department? CJEM. 2011;13(2):96-104. [PubMed]
  11. Andolfatto G, Willman E, Joo D, et al. Intranasal ketamine for analgesia in the emergency department: a prospective observational series. Acad Emerg Med. 2013;20(10):1050-1054. [PubMed]
  12. Yeaman F, Meek R, Egerton-Warburton D, Rosengarten P, Graudins A. Sub-dissociative-dose intranasal ketamine for moderate to severe pain in adult emergency department patients. Emerg Med Australas. 2014;26(3):237-242. [PubMed]
  13. Beaudoin F, Lin C, Guan W, Merchant R. Low-dose ketamine improves pain relief in patients receiving intravenous opioids for acute pain in the emergency department: results of a randomized, double-blind, clinical trial. Acad Emerg Med. 2014;21(11):1193-1202. [PubMed]
  14. Miller J, Schauer S, Ganem V, Bebarta V. Low-dose ketamine vs morphine for acute pain in the ED: a randomized controlled trial. Am J Emerg Med. 2015;33(3):402-408. [PubMed]
Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD


Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at Bio:
Michelle Lin, MD