Most of us are having issues with using opiates in general given problems with misuse and abuse. However, more recently we are experiencing significant shortages. We discuss some key articles in recent literature (almost exclusively 2017) to help discuss alternatives to using opiates in pain control.
Ketorolac - The Power of NSAIDs
Ketorolac (Toradol) is a great NSAID but we are using it at higher doses than needed. A well structured RCT published in the Annals of Emergency Medicine found that the therapeutic ceiling for pain appears to be 10mg when given IV but appears to be the same also for IM and PO forms. However, this can be difficult to give 10mg in the IV/IM form given its concentration and 15mg via these routes are most likely sufficient. When used orally, 10mg pills are usually used and are often sufficient.
Another RCT recently performed specifically for renal colic found that ketorolac was found to be as effective as when combined with morphine or if morphine was given on its own. However, combination therapy did have the lowest rates of needing rescue analgesia and ketorolac was slightly higher. Given the overall safety profile and its very similar effectiveness, ketorolac continues to appear to be a strong first-line agent.
Ketamine - An Old Drug Lives Again
Speaking of renal colic, another recent study used intranasal ketamine versus IV morphine had similar pain control but the IN ketamine took longer than IV morphine (which makes sense). Rescue analgesia was less frequently required with ketamine than morphine but was not statistically significant (even though there was an approximately 10% difference).
Combining ketamine to opiates has demonstrated extra benefit in a recent SAEM published RCT. That trial demonstrated that the synergistic effect of ketamine to opiates is powerful and when adding ketamine to previously administered opiates led to a greater improvement of pain control as well as requiring fewer doses.
When giving ketamine for pain control, there is a debate of infusion versus push dosing. Thanks to a new RCT in AJEM it was found that although they both have the same pain control, a 15 minute IV infusion versus a 5 minute push led to a decrease in side effects including the feeling of unreality.
Ketamine is not the only option when it comes to using non-opiate medications. When comparing different oral options in a recent JAMA published RCT, 400mg of ibuprofen and 1000mg of acetaminophen was just as effective statistically and clinically for pain control compared to opiate options of codeine, hydrocodone, or oxycodone when adding acetaminophen. However, the combinations used may have been less than optimal to truly demonstrate similarity.
Pills and IVs are not the only options for pain control. Nerve blocks are frequently used and accepted for pain management. It also helps us avoid some of the potential complications that arise when using large amounts of pain medications. This study demonstrated femoral nerve blocks followed by continuous fascia iliaca blocks result in better pain control, improved mobility, improved functional status with significantly less opioid side effects when compared to IV opioid analgesia.
Headaches Do Not Need Opiates
Finally, although most people would agree that headaches should not be treated with opiates, a recent study compared 10mg of IV prochlorperazine (Compazine) and 25mg of diphenhydramine (Benadryl) to using 1mg of hydromorphone (Dilaudid). The primary outcome (quick and sustained headache relief) was achieved in 60% of the IV prochlorperazine + diphenhydramine group versus 31% in the IV hydromorphone group with a NNT of 4.
We need to avoid opiates in general whenever possible. Although effective for pain control, we have barely touched all the potential complications. Other medications can potentially cause side effects but it is our duty to know other options.
Also feel free to check out other sources regarding opiate alternatives. REBEL Cast has a recent podcast regarding opioid sparing options in the ED. JournalFeed is a great blog covering many of these papers mentioned.
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