Monday, January 25, 2016

Opioid-Free Emergency Departments-Would You Go There?

In the article Opioid-Free ED: Coming Soon to a Hospital Near You, the author makes a case for an Opioid-Free Emergency Department. His concerns were for the potential drug abuse through narcotic prescription writing and eliminating a percentage of patients who are drug seeking.
He offers a table for alternative treatments.
Table. Non-opioid Alternatives for Pain Management



Renal colic

acetaminophen, indomethacin, ketorolac, lidocaine, rectal indomethacin

Back pain

acetaminophen, diazepam, ibuprofen, lidocaine patch, methocarbamol, trigger-point myofascial injections


diphenhydramine, ketorolac, metoclopramide, prochlorperazine, sumatriptan,

Musculoskeletal pain

acetaminophen, ibuprofen, lidocaine patch, naproxen, nitrous oxide, regional nerve blocks

Neuropathic pain

clonidine, gabapentin, ibuprofen, nortriptyline, pregabalin


acetaminophen, bupivacaine, ibuprofen, naproxen, nitrous oxide

Sickle cell crisis

hydroxyurea, ibuprofen, ketamine, nitrous oxide

Chronic pain

gabapentin, ibuprofen, lidocaine patch, prednisone, trigger-point injections

Pediatric pain

acetaminophen, ibuprofen, ketamine, nitrous oxide

Regarding this opioid-free approach, we have an alternative point of view; and it is backed by years of experience and success with narcotic-based analgesia when properly used.

There are certain conditions that narcotics definitively benefit, especially in their acute phases. Consider heart attacks, severe visceral (abdominal) pain, multiple injuries, fractures, ruptured disks, intubation & procedural sedation, sickle cell, cancer patients, etc., etc. Do you really want to practice without morphine or its derivatives as options?

Narcotics are easily titrated with proper protocols and PCA (patient-controlled analgesia) pumps. Most studies show that pain (as a presenting or prominent symptom) is the #1 or #2 reason for going to the Emergency Department.  Not uncommonly, once seen, it is undertreated.

What can be done? Balance is needed in clinical emergency medicine, and with care, a common sense practical approach can be reached. During any one patient encounter, the ED clinician should not impede his/her decision-making process by deliberating political correctness or evoking concern for the vast social ills that abound in the culture.  These are surely not the priority of the patient in front you, and so they should not be yours either, at least not during the encounter. Helpful failsafe protocols can capture some offenders, and some issues, but they are not perfect.  For example, refills can be limited or non-existent; a statewide or local e-prescribing history can limit repeat prescriptions to prior offenders without verification..

The bottom line: treat pain. Treat it strongly.  It is one of few things we can reliably do for people. (Yes, there are others, but the list of interventions that really make a perceptible difference is shorter than we would like it to be).  Remember the last patient you relieved of pain, and keep that image in mind. And if a member of my family is in desperate pain, please take care of them. Mo-phine would be just fine.

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