Managing Patients and Opioid Epidemic in Pre-hospital Setting
byBrian M. Light MS.
While many systems are dealing with the opioid crisis few, if any in the industry are given alternatives to narcotic pain management in the field. A high amount of those who we come into contact with may have better outcomes and shorter stays by administering other non-narcotic medication in the field. Many patients also may not receive pain management as they are seen as not needing the level of medication available pre-hospital. Better and more global means of pain management are necessary. Alternatively, many times field staff are contacting with patients who abuse the system and may be calling an ambulance because they are abusing narcotics through seeking service. Non-opioid pain management options could have a significant impact on many of these issues. Many issues in the field could be addressed in a safe, effective manner by introducing NSAIDs pre-hospital.
With smaller studies, we find that a high percentage of patients are turning to opioids for pain management. With this use, patients are also staying on the prescription medications for longer periods of time. Over half the patients in a pain study with back pain turned to using opioids for pain relief. Fifty seven percent of patients have seen multiple doctors to seek out various types of treatment in most pain management cases. Beyond the fact that most patients are using narcotic pain management, many are using for longer periods of time, and larger quantity. Many patients in the same study were using opioids for six months or greater beyond the start of treatment (5).
The FDA and many other organizations have become involved in the opioid epidemic that is found in the US currently. The FDA has changed labeling guidelines to manage the use of pain management better through better education and direction. Under these guideline changes, they are stating the new recommendations for the use of OTC and prescription pain medicines prior to use of narcotics. The FDA no longer recommends prescription medications for moderate pain when it can be managed with less addictive means. The removal of labeling is to promote the use of NSAIDs for moderate pain. Nearly 23 million Americans have used NSAIDS for the relief or management of pain safely. The overall safety of these drugs is much greater without the risk of long term dependence (6).
Many of the patients contacted in the field have lower levels of pain then what many pre-hospital providers are equipped to treat. Patients in the study who felt no pain represented 32 percent of one-third of the total population. Patients outside this percent were able to rate their pain between moderate to severe and then unbearable. Patients who rated their pain at either severe or intolerable made up 15 percent of the population who had admitted to pain. This 15 percent are good candidates for opioid pain management. Under the new FDA guidelines for treating slight to moderate pain with NSAIDs, a greater patient population can be treated. Mild to moderate pain was seen in nearly half of the patient population at 48.5 percent of those in the study. In field, however, the number of pain management medications is limited at best (1)
What has been historically available in pre-hospital is different than what is seen as the current need. While the majority of pain is considered moderate, the type of medication available is limited to management of severe pain. In the prehospital environment, almost 80 percent of the available drug is morphine. Patients with mild to moderate pain are being given either stronger opioid pain medications or nothing, as the pain does not warrant stronger medications. Of the 28 percent of other medications accessible in prehospital, 25 percent are NSAIDs and share that 28 percent with other drugs like Ketamine. This means that of the total available drugs, only 7 percent account for NSAID or management of moderate or lesser pain (1).
The increase in the need for pain management is necessary, however using the right level of medication for the right job is key. Under the World Health Organization(WHO) guidelines for the treatment of patients outlines these types of variations in treatment. Controlling pain is seen as a need in medical care as pain and morbidity are directly linked. WHO has recommended a stepwise system of pain management. This means using specific medication as related to the type or severity of the pain. This means starting off with OTC, as we see many NSAIDs in this class. Then moving on to stronger non-opioid pain management with prescription medication and then lastly to prescription opioids (2)
NSAIDs are not new to the management of pain as many use them are used safely every day. Most NSAIDs found all over the world are sold Over the Counter (OTC) without a prescription and at any neighborhood retailer. Much of the data on the use of these medications is much older as these have been approved over 20 years or more prior. The use of drugs is mostly seen by either chronic pain sufferers or the acute pain from exercise induced stress. Some studies put the use of NSAIDs up to 28 percent of adults, the major difference is between women who use more than men. This is a large enough cross section with a very low incident of side effects. Pain management is increasing on all levels, and the FDA is still trying to manage this at every level of medication use. (3)
For better patient care, more options need to be available to patients and providers. Patients are being treated improperly or not at all because of the lack of resources. In the United States, there is currently what is well known as an opioid abuse epidemic. Some patients may better be managed with other types of medication. Less access to opioids may lead to a decrease in chronic users abusing the system because of a lack of availability. Many believe that EMS should treat pain no matter the prior history, but this will eliminate the question. Many times, with stronger pain management, patients will have longer stays in the ER because of opioid management. NSAIDs may be able to increase patient turnaround time in the emergency setting. On many levels, this could decrease patient loads in already overwhelmed emergency rooms and staff. Many Emergency rooms are also changing pain management protocols for the same reasons to better manage patients and an ever-increasing opioid problem
(1)Marinangeli, F., Narducci, C., Ursini, M. L., Paladini, A., Pasqualucci, A., Gatti, A., & Varrassi, G. (2009). Acute Pain and Availability of Analgesia in the Prehospital Emergency Setting in Italy: A Problem to be Solved. Pain Practice, 9(4), 282-288.
(2)Wertli, M. M., Reich, O., Signorell, A., Burgstaller, J. M., Steurer, J., & Held, U. (2017). Changes over time in prescription practices of pain medications in Switzerland between 2006 and 2013: an analysis of insurance claims. BMC Health Services Research, 171-11. doi:10.1186/s12913-017-2086-6
(3)Dale, O., Borchgrevink, P. C., Fredheim, O. S., Mahic, M., Romundstad, P., & Skurtveit, S. (2015). Prevalence of use of non-prescription analgesics in the Norwegian HUNT3 population: Impact of gender, age, exercise and prescription of opioids. BMC Public Health, 15(1), 1-9. doi:10.1186/s12889-015-1774-6
(5)The Best and Safest Ways to Ease Pain. (2017). Consumer Reports on Health, 29(8), 4.
(6)PR, N. (2013, September 13). Alliance for Rational Use of NSAIDs Calls for Appropriate Use of NSAIDs in Wake of New FDA Guidelines on Opioid Use. PR Newswire US.