Non opioid pain options

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.

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.

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We do IV acetaminophen relatively frequently. We do toradol for things like pancreatitis and it seems to work much better than morphine or dilaudid. That being said, we also sometimes have to pick the lesser of the two evils if someone comes in with acute renal failure, with liver issues, or with somenthibg like a GI bleed. Tylenol is almost always ordered PRN unless there are liver issues.

Our ED would sing some hallelujah choruses if someone said they'd rather have Tylenol.

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I give Tylenol and ibuprofen all day long. It's not that it's never given, it's just that those pts don't seem to get admitted much, thus you don't know about them.

Regarding your pts - you weren't there when the ED doc assessed them so you don't actually know what was said or observed about their pain. It's possible they were sweating, clutching the rails and borderline unexaminable and still calling their pain a 3. Tylenol may work now because dilaudid gave them the initial relief they needed.

If you see it in every single ED pt in recent memory, then you may be seeing more of a culture/practice pattern.

IV Tylenol is expensive and has limited use when 4mg of morphine will do. Toradol (IV ibuprofen) is pretty much only used for kidney stones, resistant musculoskeletal pain, and occasionally in migraine cocktails.

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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.

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IV Tylenol is mega expensive. It's brand name and no generic. I always tell my patients what I am giving them beforehand but if the ED nurse asked them to rate their pain and they rated it say a 7 or 8, Tylenol is doing nothing and I'm sure the pain order set says to give a certain med for pain rated a certain number. Thus, they were given dilaudid.

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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.

I agree with the points already made above.

In order to more fully understand the overall situation, I recommend reading about its history and evolution. There are agencies, organizations, advisory committees, accrediting bodies, etc., etc., who had a hand in this, still do have a hand in it, and will need to be part of any solution.

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Specializes in Neuroscience.

A single dose of a narcotic is not going to cause the opioid epidemic we see now, and there are certain times when it is important to get the pain under control. If your patients are coming up stating that a tylenol will be sufficient, they aren't addicted. I promise.

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Specializes in Critical Care.

IV Tylenol is great in certain conditions and scenarios. At my facility IV Tylenol is preferred to have an anesthesia or pain management sign off. It can be overridden by the resident but it entails justifying etc.

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I work in the UK and paracetamol IV (acetaminophen) is first line treatment for surgical pain then opioids. It is very safe if it is given max 4g in 24h and the dosing is 1g every 4-6h. I have seen many cases when patients still complained of pain despite being given quite good dose of opioids. Often the dose of IV paracetamol killed the pain instantly. Wheter it is so powerful, placebo or improve the opioids action it is mystery but works well.

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Specializes in Critical Care, Capacity/Bed Management.

Ofirmev or IV acetaminophen works quite well, especially in the post operative patient. I have seen huge ex-laps on 1 gram q6h and rate their pain 1-2.

Of course as other people mentioned ofirmev is quite expensive and is used sparingly for that reason, the risk of causing liver failure is the same as PO tylenol so the max dose is 4g/24 hour period.

My facility utilizes three pain medications for a patients PRN meds. For example, a post op patient may have Tylenol 650mg PO Q4h for mild pain (1-3), percocet 5-325 q4h for moderate pain (4-7) and percocet 10-650 q4h for severe pain (8-10). This way all the bases are covered.

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Toradol (IV ibuprofen) is pretty much only used for kidney stones, resistant musculoskeletal pain, and occasionally in migraine cocktails.

Do you mean to say that Toradol is the IV formulation of ibuprofen? That's incorrect. They are both NSAIDs, but ketorolac (Toradol), whether IV or po, is a different medication than ibuprofen (Motrin(po), Caldolor (IV), NeoProfen (IV)).

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A single dose of a narcotic is not going to cause the opioid epidemic we see now.

Of course not, but it could cause a relapse in an opioid-dependent individual who is in recovery.

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