Should Antiemetics be Given Prophylactically with Intravenous Opioids While Treating Acute Pain in the Emergency Department?

Parenteral opioids are the most common analgesics used in the emergency department (ED) for relief of acute pain. Gastrointestinal side effects such as nausea and vomiting are common following opioid analgesia in long-term therapy for malignant and chronic pain and are considered a limiting factor in effective pain therapy.1 Despite the lack of clear and supporting evidence, it has been common practice to prophylactically use antiemetics when administering intravenous opioids in treating acute pain in the ED. The recent literature is challenging this concept and advocating against the prophylactic administration of antiemetics in the ED, as the incidence of vomiting associated with opioid administration for acute pain is low. Given concerns for the additive sedative and extrapyramidal effects of many anti-emetics when coadministered with opioids, the routine use of prophylactic antiemetics likely causes far more adverse effects relative to episodes of vomiting prevented.2-4 The existing research is limited in terms of the antiemetics used (mostly metoclopramide), however more recent studies have evaluated ondansetron as well. Other studies have found certain risk factors that are associated with a higher incidence of nausea and vomiting after opioid administration. The overwhelming evidence shows a low incidence of nausea and vomiting after administration of opioid analgesics in the ED.

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Reviewed and approved by AAEM Board of Directors. (6/7/2019)