Managing Patients and the Opioid Epidemic in a Prehospital Setting

By Brian M. Light, MS, NREMT-P – JEMS

While many systems are dealing with the opioid crisis, only some in the industry may have alternatives to narcotic pain management in the field. A high number of those whom we come into contact with may have better outcomes and shorter stays by administering other non-narcotic medication in the area. Many patients may also not receive pain management as they are seen as not needing the level of drugs available prehospital because the pain does not warrant narcotics, such as fentanyl or morphine. Better options for medications with varying degrees of pain management are necessary.

Alternatively, field staff are contacting patients who abuse the system and maybe 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 prehospital.

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 prescription medications for more extended periods. Over half the patients in a pain study with back pain turned to use opioids for pain relief. Fifty-seven percent of patients have seen multiple doctors seek out various types of treatment in most pain management cases. Controlling access to medications to prevent this is incredibly important. Beyond the fact that most patients are using narcotic pain management, many are applying for an extended period, and a larger quantity is driving the demand for more. Many patients in the same study were using opioids for six months or more significant beyond the start of treatment where many believe addictions start.4

The FDA, and many other organizations such as WHO, have become involved in the opioid epidemic in the United States. The FDA has changed labeling guidelines to manage the use of pain management through better education and direction. Under these guideline changes, it now states the new recommendations for non-prescription and prescription pain medicines before the use of narcotics, scaling the pain management to the patient and increasing doses gradually.

The FDA no longer recommends prescription medications for moderate pain when it can be managed with less-addictive means. The removal of labeling promotes the use of NSAIDs for mild discomfort over the use of narcotics. Nearly 23 million Americans have used NSAIDs for the relief or management of pain safely over short periods. The overall safety of these drugs is much higher without the risk of long-term dependency or the need to increase over time as dependence increases.5

Many of the patients contacted in the field had lower levels of pain then what many prehospital providers were equipped to treat. Patients in the study who felt no pain represented 32 percent of the total population. Patients outside this percent were able to rate their pain between moderate, severe and 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 more significant patient population can be treated. Mild to moderate pain was seen in nearly half of the patient population (48.5 percent of those in the study.) In the field, however, the number of pain management medications is limited at best.1

What has been historically available in prehospital 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 the management of severe pain. In the prehospital environment, nearly 80 percent of the available medication for pain is morphine. Patients with mild to moderate discomfort are given either stronger opioid pain medications or nothing, as the pain does not warrant stronger medications. Of the 28 percent of other medicines 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 seven 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 critical. World Health Organization guidelines for the treatment of patients outlines these types of variations in treatment. Controlling pain is seen as a need for medical care, as pain and morbidity are directly linked. The World Health Organization has recommended a stepwise system of pain management. This means using specific medication as related to the type or severity of the pain. This also means starting with OTC, as we see many NSAIDs in this class, then moving on to stronger non-opioid pain management with prescription medication. If that does not work, prescription opioids should be administered.2

NSAIDs are not new to the management of pain as much of the population throughout the world uses them safely. Most NSAIDs throughout the world are sold without a prescription 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 by acute pain from exercise-induced stress. Some studies put the use of NSAIDs up to 28 percent of adults. The significant difference is between women who use more than men. This is a broad 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

Any medication is not without risk and some of these issues need to be further addressed. Concerns with the increase in HF in the patient who takes NSAIDs are common. Many of the issues with NSAIDs are found to be with patients using medications chronically. There are documented side effects in some medications, however it does not have the same effects across the class of medication.

Nonselective NSAIDs are seen to increase the risk of HF and hospital admission in at-risk patients. The recommendation with these medications is the smallest dose possible over the shortest time. There is no absolute contraindication, however, as patients with preexisting conditions may be excluded for use or decreased doses recommendations.6

Under the same study above many NSAIDs, effects are over long-term use, and little is seen in the acute setting. Further care needs to be taken when using inpatient needing possible contrast in hospital. The renal effects have been seen to increase, with the elderly being at the highest risk for renal damage from NSAIDs. As age increases, care in use of lower and short-term dosing must be used. Patients needing contrast and possible bleeding or trauma have increased risk with NSAID use.

Issues with bleeding associated with these medications are also concerning as we use these to inhibit clotting in cardiac patients. Currently, while most studies look at bleeding and platelet aggregation problems with chronic use, no study has found acute use of one time or several small dosing being administered in lower and short-term duration. Major bleed requiring hospitalization in one study ranged from 1.77% to 2.15% of the population determining very low risk for bleeding.7 These are both with spontaneous bleeding — or patients who are post-operative — with both being at a higher risk of bleeding than the general population.

Pregnancy causes a risk to the fetus directly with the use of NSAIDs. These are normally caused after 30 weeks of gestation. Most patients by this point are well aware of the pregnancy and seeking prenatal care. Recommendations for NSAID use in the field is if the benefit to the mother outweighs the risk to the fetus. Given our target population, these patient’s benefit does not, however, pregnancy comes with many of these issues of medications being risky. While APAP and opioids have also been found to have complications during pregnancy, it does have considerably fewer complications.8

Conclusions

More options need to be available to patients and providers for better patient care. Patients are being treated improperly — or not at all — because of a lack of resources. In the United States, there is currently a well-known 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 times in the ER because of opioid administration.

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. Many emergency rooms are also changing pain management protocols for the same reasons to better manage patients and an ever-increasing opioid problem. NSAIDs are by no means the only option.

Many systems are also using acetaminophen in the field in intravenous and prescription doses available under medical control. While both have side effects, the contraindications with APAP are fewer than that of NSAIDs such as Ketorolac that is also used in the field in some areas. APAP is used in pregnancy a great deal more, however this may be a much smaller population. Every system may find they have different needs and ultimately choose the medication right for their system.

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