Non opioid pain options

[JBMmom]

I am on a med surg floor and recently I've had two occasions where patients were admitted to the floor and then asked for pain meds, both had been given dilaudid in the ED and that was the only prn pain med (other than tylenol for fever or pain). I always ask people whether the medicine they got in the ED was effective and did it make them nauseous, dizzy or sleepy. I ask if they've taken opioid pain medications in the past. These women both said they don't want opioid medications, one said she has a family history of alcoholism and wouldn't want opioids. They said no one in the ED told them what they were getting for pain.

I'm no pain expert and I don't work in the ED, I'm just looking for information, not pointing fingers. I'm sure that many people need narcotics, but one of these women reported that the tylenol was effective for her pain (her pain was 3-4, same that she reported in the ED and she got 0.5 mg dilaudid), but tylenol wasn't given in the ED. When someone comes to the ED, why are they often given opioids without trying anything else? Is it the speed of onset? I never see IV acetaminophen or ibuprofen, but I know they exist, does anyone use them?

With all the information about the current opioid crisis, I just wonder whether the medical system could be adding to some of this problem by so quickly administering opioids for any pain. I'd like to learn more about this if anyone has experience. Thank you.

[PeakRN]

When someone comes to the ED, why are they often given opioids without trying anything else? Is it the speed of onset? I never see IV acetaminophen or ibuprofen, but I know they exist, does anyone use them?

With all the information about the current opioid crisis, I just wonder whether the medical system could be adding to some of this problem by so quickly administering opioids for any pain. I'd like to learn more about this if anyone has experience. Thank you.

Often when patients present to the Emergency Department they are presumed to be surgical candidates and are NPO until proven otherwise. Oral medications are therefore not an option and very few patients are interested in a suppository (and often are still contraindicated). Belly pain can be caused by liver or kidney damage which further decreases our desire to give Tylenol or NSAIDs in the ED. NSAIDS also prevent some platelet aggregation so we tend to avoid them in suspected surgical cases (although there are studies emerging that suggest that this is far less than was thought).

IV Tylenol is not often stocked in emergency departments and in addition to the added difficulty of administration over other medications (which means a higher risk of med errors, which should not be quickly dismissed) it also takes quite a while to get the medication, and then even longer to start working for their pain. In the past year I have given IV Tylenol once in the ED, and it was for a complex pediatric case who was on gut rest but presented to the ED with a fever, the GI team didn't even want us to give suppositories.

Narcotics have relatively few side effects, especially since there are few better places to have those side effects treated than in the ED. Often the benefits of quick onset are not just to help the patient feel better but so that we can image, assess, or perform other treatments.

We do use many non-narcotic treatments, although this varies from ED to ED. We use low dose ketamine, low dose IV lidocaine, lidocaine patches, tylenol, NSAIDs (both IV and otherwise), reglan, benadryl, phenergan, hematoma blocks, beir blocks, nerve blocks, local anesthetic infiltration, nitrous oxide, heat therapy, cold therapy, compression, elevation, and a myriad of other medical and adjunct treatments for pain. More likely than not you are seeing the patients with more acute medical conditions and therefore are more likely to receive narcotics. We discharge many patients after giving them an ace wrap and an ibuprofen.

[Elfriede]

I´ve heard about a "jointcommission.org"/pain management.

Maybe a source of information?

[mircats]

I'm in Australia, and IV paracetamol (acetaminophen) is used a lot, particularly post-op. Part of the reason is that for some reason it does help opioids work, and in itself can be beneficial for many types of pain. From personal experience, I have found that particularly with bone pain (so, eg, after orthopaedic surgery) it does help. I didn't think it would, but was pleasantly surprised.

[kbrn2002, ADN, RN]

Not an ED nurse here so I can't speak to narcotic use in that setting. Where I do have a ton of experience is in LTC. FInally over the last year or so narcotic reductions have been happening. My narc drawer on the med cart used to be so stuffed full you could barely fit another card of meds in it, now I am down to a half dozen prescriptions and a few of those are rarely if ever used.

The ones that are used are in much lower doses that we used to see. I don't have a single resident on percocet or hydrocodone/APAP in a dose larger than 5/325. No fentanyl patches anymore, no MS except for a few Hospice patients. When an opioid is scheduled it's usually tramadol which until fairly recently wasn't even categorized as a controlled med. I haven't seen any overall increase in pain levels associated with opioid reductions.

Very rarely we do have a resident that truly does need an opioid for pain control but for the most part scheduled tylenol seems to work just fine.

[ebierly]

Off topic but always make sure with narcotics that there's a bowel regimen too to prevent constipation. Other pain relief techniques you could use is heat or ice if clinically permissible or lidocaine patch, pain creams

[gettingbsn2msn, MSN, RN]

Unfortunately, cannabis. However, it will not be federally legal until the pharmaceutical companies know how to package, dispense and make money. We are most likely 20 years away from that. It will also require FDA trials. However, look at the data of narcotic addictions in the legal states. Yes, they still have issues but they do not share the same levels of heroin epidemics. I agree that someone with alcohol addiction should NOT be on Dilaudid.

[zoidberg, BSN, RN]

for those people with ALL the pains.... opiate(s), robaxin, APAP, gabapentin, lidocaine patches, heat and ice.

[3ringnursing, BSN]

It's obvious to me the time is ripe for research for a different type of non-opioid, nonaddictive pain medication. Soon.

Many people have significant pain yet pain meds stop working, or they worry it could be taken away after years of use.

As for your ER question, I haven't a clue. Many ER's give nothing even if it is warranted, while some give in the scenarios you described.

[mircats]

Many people have significant pain yet pain meds stop working, or they worry it could be taken away after years of use.

It's already happening - many patients with chronic pain in the US are being taken off their current opioid pain meds, often despite having been on the same dose for 15+ years.

[erniefu, BSN, RN]

Given that a lot of medical surgical patients are NPO before surgery in ER, I think that it makes sense that dilaudid is ordered as subq prn. Unless there is an abundance of IV Tylenol that can be given. Of course if it is post op care then you can advocate for non-opioid pain management if appropriate.

[jodispamodi]

We use alot of IV tynelol. Its usually scheduled and sometime prn for mild pain, also use alot of IV toradol as well as opoids.

[MrNurse(x2), ADN]

I have been blessed to hear this from a pretty well known pain management specialist. I feel compelled to tell all I can. Dilaudid will forever change a person's response and tolerance to pain. Studies show as little as one dose will increase tolerance forever, not transient, not unusual as recreational drugs have done this, but the scarier half of this equation is it resets your pain perception. What you considered a 4/10 before Dilaudid will now be perceived as a 6/10. My wife received it during a trauma admission and has stated this before the study was ever performed. Dilaudid is used as a front line analgesic, as the OP has observed, but we are creating a pain management monster thinking we are winning the war when all these won battles will add up to a loss.