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.

[NurseKatie08, MSN]

I personally have never seen IV Tylenol. I imagine it's not routinely used because of the risk when opioids have less risk for more effect.

Worst case, if a patient gets too much opioids, we give them narcan and they wake up. It works quickly and can have a short half life (ie fentanyl). You don't have to be as concerned about hepatic/ renal impairments for excretion.

Worst case for Tylenol, we destroy their liver and they need a transplant. It has a half life of 2.5 hrs and the patient needs a 36hr mucomyst protocol to eliminate the Tylenol/ protect the liver. Given that is much easier to just give po/pr with a much less chance of adverse effects, it makes sense to me why we don't give Tylenol IV.

That being said, there should be a discussion between the nurse and patient about how the patient wants to manage their pain. I try and let patients know what they are getting, however there can be constraining factors. Was the patient strict NPO? How was their kidney and liver function tests? I'm not going to give a hepatitis patient Tylenol. I have had situations where patients refuse narcotics, Tylenol and ibuprofen are contraindicated and it comes down to you can either have narcotics or be in pain. Proper pain and narcotics teaching is important for these.

I'm starting to see Nabilone prescribed occasionally in these situations, but it definitely is not the first drug of choice.

I work on a pre & post op liver transplant unit...I agree that pain management in certain situations can be tricky. The trickiest population I see is those in end stage liver disease. ESLD is definitely painful (holy ascites, batman!) but our options for pain management are exceptionally limited. Opioids can potentiate hepatic encephalopathy, they can't have NSAIDs because they are already huge GI bleeding risks as it is, and too much Tylenol is contraindicated (we usually limit to 2g but only use it in some situations). It's really tough.

[Agatha12]

So what analgesia do you give usually?

[Not_A_Hat_Person, 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.

My state has a heroin crisis *despite* medical marijuana being legal for a decade.

[Been there,done that, ASN, RN]

Many patients are on blood thinners , they should not have NSAIDS. Dilaudid is given in the ER to shut them up. (treat 'em and street 'em). Once they hit the floor the prudent nurse assesses the patient ..and goes from there.

[NurseSpeedy, ADN, LPN, RN]

So many of the patients that come through my hospitals ER have a history of Hep C or ETOH that unless they checked their liver enzymes before treating their pain I could see why the ER doc opted for 0.5mg of Dilaudid before sending them to the floor to be admitted instead of Tylenol. Years ago I had a few patients with Hep C...now, honestly, its over half of my assignment. Add diabetes and vancomycin to stress the kidneys...unfortunately what other options do we really have? Dilaudid is a bit overkill, but we are pretty much limited to narcs when Tylenol and NSAIDS are taken off the table.

[MunoRN, RN]

So many of the patients that come through my hospitals ER have a history of Hep C or ETOH that unless they checked their liver enzymes before treating their pain I could see why the ER doc opted for 0.5mg of Dilaudid before sending them to the floor to be admitted instead of Tylenol. Years ago I had a few patients with Hep C...now, honestly, its over half of my assignment. Add diabetes and vancomycin to stress the kidneys...unfortunately what other options do we really have? Dilaudid is a bit overkill, but we are pretty much limited to narcs when Tylenol and NSAIDS are taken off the table.

There's no reason why patients with Hep C can't have any Tylenol. There are recommendations to limit Hep C patients to 2 Grams per day when taken continuously. For chronic liver failure in general there is also no reason to completely avoid Tylenol, it should be avoided in those with severe, acute liver failure, which are pretty obvious just from looking at them.

[NurseSpeedy, ADN, LPN, RN]

There's no reason why patients with Hep C can't have any Tylenol. There are recommendations to limit Hep C patients to 2 Grams per day when taken continuously. For chronic liver failure in general there is also no reason to completely avoid Tylenol, it should be avoided in those with severe, acute liver failure, which are pretty obvious just from looking at them.

This is good to know. In reason years I've gotten used to being denied even a single order to get a temp down on a patient and their history is the rationale that I'm given for the reason. So I usually get a low dose of ibuprofen to help bring it down instead.

[BostonFNP, APRN]

This is good to know. In reason years I've gotten used to being denied even a single order to get a temp down on a patient and their history is the rationale that I'm given for the reason. So I usually get a low dose of ibuprofen to help bring it down instead.

Benson, G. D., Koff, R. S., & Tolman, K. G. (2005). The therapeutic use of acetaminophen in patients with liver disease. American journal of therapeutics, 12(2), 133-141.

[NurseKatie08, MSN]

So what analgesia do you give usually?

Sorry, just seeing this now. Assuming this is in response to me. Unfortunately, not much. Usually low-dose Tylenol (maybe 650mg every 8 hours tops) or low dose Tramadol (something like 25mg every 12 hours). Generally pain meds aren't even ordered PRN for these patients--they are typically 1 time orders as we have to assess on a case by case basis. A lot of heat, repositioning, non-pharmacological stuff is sometimes all we can do. It's really awful.

[K+MgSO4, BSN]

My department sees many narcotic bowels. These patients have been on ever expanding doses of narcotics to the point of complete bowel dysfunction. We admit them for a week for a delightful combination of bowel prep and Ketamine infusion to attempt to reset their pain perceptions. Patients have to be agreeable to this protocol and are admitted as an elective rather than in a crisis via ED.

Another part of my ward is acute geriatic orthopaedic surgery. These oldies are at extreme risk of post operative delirium and as such we avoid PO narcotics with a transdermal patch, femoral blocks, small doses of Targin and paracetamol. There is the odd one who will need multiple PRNs but we are reducing our post op delirium which is fantastic.

[brillohead, ADN, RN]

I had outpatient knee surgery a few months ago. In the recovery room, I had an almost absent respiratory drive. I'd hear the pulse-ox alarm and have to consciously tell myself to breathe... at one point looked up at the shrieking monitor and was satting 78% and still felt no "need" to breathe -- but I did anyway just to shut the darn alarm off. This is normal for me with anesthesia -- it takes me FOREVER to clear it from my system.

So anyway, the nurse asked me three different times to rate my pain. I answered each time with either a 3 or a 4 -- never higher than that. Each time she asked me if I wanted some Fentanyl. All I could think was, "What, do you really want to have to intubate me? I'm hardly even breathing as it is!" Since when is 3 or 4 out of 10 considered to be a NARCOTIC level of pain??? That's OTC pain to me!

At discharge, I was given a scrip for 30 Norco tablets. This was for a simple arthroscopic meniscectomy procedure! Needless to say, at my 10-day post-op office visit, I ripped the NP and MD a new butthole about over-prescribing narcotics and contributing to the opioid crisis. I work on a cardiopulmonary and general medical floor, and the number of patients on narcotics for "chronic pain" is staggering.

A while ago I floated to the post-surgical floor, and all my patients were getting scheduled Tylenol, Celebrex, and Neurontin, and it was working like a charm. I was also given Celebrex and Neurontin by the anesthesia team immediately prior to surgery (like literally five minutes before they wheeled me in... so much for NPO status!) as a "head start" for post-surgical pain control... but then my only options after surgery were Fentanyl and Norco??

Everyone needs to get on the same page here.... surgeons and anesthesia and ER docs and hospitalists and general practitioners. Something has to change!

[AceOfHearts<3]

I was recently in an accident that left me with a severe orthopedic injury- it was obvious without the X-ray. I required many doses of IV narcotic pain meds in the ER to even touch my pain. When in the ambulance they told me what drug they were giving me, but they didn't in the ER- I had to ask what it was. I received excellent care- don't think it could have been better- but they didn't tell me the drug or dosage amount (I was in my hospital and due to the circumstances of my accident it was known that I am a nurse).

I had surgery and went home that day. I took Percocet every 4 hours POD1 or else I was in severe pain, POD2 I took it every 6-7 hours, and POD3 I took myself off of it- I now alternate Tylenol and Advil as needed, sometimes going almost all day without needing anything. I have a good amount of Percocet left, but I have to say the level of pain and needing it every 4 hours POD1 initially had me concerned that I was going to run through all the pills. I am opioid naive and this was my first surgery.