Use of non-opioid analgesics as first line treatment for acute pain management by emergency medical services providers
Shiba, Steven Kiyohiko
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Pain is the universal symptom of illness and trauma. It affects people of all ages, cultures, and backgrounds, causing distress and suffering. Appearing in a plethora of diagnoses, almost all patients will experience some type of pain as a related symptom during their lifetime. The ubiquitous nature of pain renders it likely that a wide variety of healthcare providers will treat patients reporting pain in both the acute care and longitudinal settings. Many institutions and governing bodies in the medical sphere have emphasized the duty of the medical field to treat pain and thereby alleviate suffering. It is common for Emergency Medicine (EM) physicians to manage patients presenting to the Emergency Department (ED) in pain. Although these patients’ etiologies for their pain may differ, most will be experiencing pain from an acute insult. Emergency Medical Services (EMS) is the extension of EM into the prehospital setting. As such, EMS providers interact with many of the same patients experiencing acute pain. Despite the prevalence of pain and the importance of alleviating it, acute pain management has often been inadequate. Improving pain management should continue to be a high priority. Opioid analgesics have long been the standard of care for acute pain management. The first opiate, morphine, was isolated in the early 1800’s. Opioids are potent analgesics and are titratable to effect. However, they have a significant adverse effect profile. Among other adverse effects, opioids can cause hypotension and respiratory depression. In addition, the United States opioid epidemic has placed increased pressures on EMS and the entire healthcare profession to utilize opioid alternatives while continuing to improve the quality of acute pain management provided to patients. As a result, non-opioid analgesics have gained increased attention and use in EMS. They generally have fewer adverse effects than opioids and are not typically associated with a potential for addiction and abuse. However, the individual and subjective nature of the pain experience increases the difficulty of achieving improved analgesia. EMS providers must weigh these various factors and the complexity of the pain experience when determining the most appropriate treatment for acute pain. This review seeks to determine if non-opioid analgesics have potential for use as first line treatment by EMS over opioid analgesics, the standard of care for acute pain management. The purpose of this review of the current literature, especially comparison studies, is to investigate the common EMS analgesics: morphine, fentanyl, acetaminophen, ketorolac, ibuprofen, nitrous oxide, methoxyflurane, and ketamine. The findings are discussed in relation to four important outcome measures identified: effect on pain severity, rescue analgesic use, patient satisfaction, and the consideration of risks. Due to the paucity of research on this important topic, a general recommendation cannot be made for the use of non-opioid analgesics as first line treatment for acute pain management by EMS. However, this review provides several specific suggestions regarding the use of non-opioid analgesics as first line treatment by EMS. Applicability concerns are addressed, and a protocol is presented that EMS could use to adapt the findings to existing protocols.
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