Intranasal ketamine versus intravenous opioids for acute pain in the emergency department: A scoping review.

INTRODUCTION

The need for alternative analgesia to opioids in the emergency department (ED) has become increasingly urgent due to the opioid epidemic. Ketamine, traditionally used for sedation, has emerged as a promising alternative for pain control in the acute care setting. This scoping review evaluates the use of intranasal (IN) ketamine compared with intravenous (IV) opioids for analgesic efficacy in treating acute pain in the ED.

METHODS

A search of PubMed, CINAHL and PRIMO databases was conducted for randomized controlled trials (RCTs) published between 2015 and 2025. A total of 561 records were identified, and 8 RCTs evaluating analgesic efficacy as the primary outcome were included in this review. This review was conducted in accordance with the PRISMA-ScR reporting guidelines.

RESULTS

Eight RCTs including 846 patients were included (2016-2025), all conducted in Iran, Israel, or Thailand. IN ketamine (0.3-1.5 mg/kg) was most commonly compared with IV morphine (0.1 mg/kg). Across studies, IN ketamine demonstrated comparable reductions in pain scores to IV morphine, with several trials reporting no statistically significant differences at measured time points, although IV morphine was generally associated with faster onset of analgesia. In one study, IV fentanyl produced greater pain reduction than IN ketamine. Adverse effects were generally mild and transient with IN ketamine associated with fewer adverse events compared to IV morphine.

CONCLUSION

IN ketamine may be useful for acute pain management in the ED. However, further research is needed to determine optimal dosing, compare its efficacy with more potent opioids, and evaluate long-term outcomes associated with its use.