{'fraction_non_alphanumeric': 0.017765933821896514, 'fraction_numerical': 0.00310903841883189, 'mean_word_length': 4.973474801061008, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Why don’t we have better pain treatments?

The effective, safe, and timely management of acute pain is critical, yet advances in pain management have come slowly. Perhaps because morphine, which was one of the first medicines available to modern medicine when it was developed in 1806, is still widely used and has only seen marginally more effective or safer alternatives come along, there has been less pressure to make advances in acute pain treatment than in other aspects of medicine. It is possible that since modern medicine got its start with an effective enough treatment for pain, that the science behind pain and pain treatment has been neglected over the past two centuries. The limitations and consequences of relying on opioids as analgesics have been described since morphine was developed, and the lack of effective alternatives and their slow development has become more apparent as we attempt to address these consequences. In this month's Academic Emergency Medicine, Brichko et al.1 describe the use of inhaled methoxyflurane versus standard care for acute pain in the ED. The first thing that stands out in this article is that there does not appear to be a big analgesic effect from inhaled methoxyflurane. There is a small difference in pain scores from standard care at the time points, and the patients in the two groups had similar outcomes, received similar amounts on noninhaled analgesics, and had similar times in the ED. Why then is this work important? There are several findings in this study that represent the great potential of this analgesic approach. The first is that the time to starting analgesia was 11 minutes. This is quite a bit faster than typical time to administrations.2 Also, giving a patient a small device to inhale from, at face value, seems like a lot less work than starting an IV and more comparable to administering a tablet but with a much faster onset. Finally, given the adverse events and broad long-term complications associated with opioids, a nonopioid analgesic represents an important advance in the treatment of acute pain. In terms of the analgesic effect, review of the acute pain treatment literature reveals that most studies with active comparators show little difference in treatment groups. Clinical practice demonstrates that every pain medicine does not work the same in every patient, so why do studies routinely show them to be the same? Pain is subjective and varies based on factors unrelated to a patient's physical injury such as mood, competing concerns, cultural expectations, and mental status, making the measurement tools used in studies too imprecise to discern anything but very large differences. Attempts have been made to develop more objective measures, but for now we are limited to subjective scales that can vary widely even for constant stimuli.3 The imprecise scales we use, therefore, make distinguishing analgesic effects between agents very difficult. We can, however, usually detect the difference between placebo and an active analgesic. In this study, the fact that methoxyflurane did not perform worse than standard means it likely has an analgesic effect. It is difficult to interpret small differences in pain scores at time points to make decisions about one agent over another, but in the case of deciding on a new analgesic route and agent, not being detectably worse is enough evidence to consider a treatment effective, and we can then focus on decisions on safety and utility. There are limited alternatives for the noninvasive management of pain. There are times when a patient may need pain treatment more rapidly than can be achieved with oral opioids, but when IV access is either not yet available or otherwise not indicated. Other than the obvious benefit of reduced suffering, the earlier administration of pain treatment is associated with earlier discharge from the ED, improved functionality, less development of chronic pain, and a reduced incidence of PTSD. Titrating analgesics is most easily done with an IV. Placing an IV, however, can be painful and time-consuming, and the fail rate for the first attempt is 12% to 26% in adults,4 and in some situation IV access is limited. Intramuscular medications are painful, and the onset is unpredictable. Oral medications have a slow onset. The development of nonparenterally administered analgesics with faster onsets than oral medications offers an alternative to establishing IV access. This model already exists for some opiates