Analgesia in Acute Abdominal Pain: What’s Next?

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In 1986, Zoltie and Cust described a group of inpatients with acute abdominal pain whom they treated with buprenorphine, a semisynthetic opiate, or placebo to determine whether analgesia could alleviate discomfort without reducing diagnostic accuracy. Before the publication of this article, clinicians adhered to the surgical dictum outlined in Sir Zachary Cope’s classic treatise on acute abdominal pain: avoid early analgesic administration in patients presenting with acute severe undifferentiated abdominal pain because it would impair clinical diagnostic accuracy. Despite some moderation of this position throughout the ensuing 10 to 15 years, the surgical and emergency medicine literature of the early 1990s reflected widespread reluctance to administer analgesia in the emergency department (ED) for patients presenting with undiagnosed acute abdominal pain. As an emergency physician (RK) and a surgeon (DD), we believe it is important to ask what we have learned in the past 10 years about analgesic administration in patients with acute abdominal pain and what our current practice should be. Many practitioners believe that there is no longer a controversy, because current practice in many hospitals supports the early administration of analgesia. However, even in the past 3 years several published articles have questioned whether the evidence supports early analgesic administration. Nissman et al commented in a survey and literature review on early analgesic administration that none of the studies adequately addressed the safety of giving analgesia without the surgeon’s involvement. Green et al published an article last year in Pediatrics, indicating that morphine relieved pain in children 5 to 16 years of age without appearing to “impede the diagnosis of acute appendicitis.” Two accompanying editorials, however, raised concerns that the quality of evidence remains inadequate to make such a conclusion. Why are medical journals still publishing articles on a subject that was first addressed 20 years ago? First, changing a long tradition is often an evolutionary process rather than a rapid or revolutionary one. From the perspective of the surgeon, accurate examination of the patient is essential to determine the need for surgery in the setting of acute undiagnosed abdominal pain. An