Opioid Alternative Analgesics in the ER
Why even consider opioid alternative analgesics in the first place?
It’s no surprise to anyone working in healthcare that there are indeed those people who are classified as “drug seekers”, lying to medical providers so they can continue to score narcotics. Regardless, nurses and Providers should still provide pain relief as best they can without bias or judgment. We can only do our best to provide the best pain relief while still being cognizant of the potential for those to take advantage. However, healthcare workers should consider opioid alternatives in many more individuals than just potential “drug-seekers”.
Opioids can provide great pain relief but also come with quite a few side effects. These include nausea and vomiting, sedation, respiratory depression, and even hypotension. These side effects tend to be more profound in the elderly, and delirium or confusion is common within the hospital. For chronic opioids, constipation can be a troublesome adverse effect. Oftentimes opioids may still be necessary, especially in acute conditions, but limiting the dose and frequency while supplementing non-opioid analgesics is a great way to reduce side effects while still providing adequate pain relief.
OFIRMEV (IV TYLENOL)
Ofirmev, or Acetaminophen, is your standard Tylenol but in IV form. Tylenol is one of the safest pain medications you can take – as long as you don’t overdose (trust me – Tylenol overdoses are NOT pretty). While Tylenol pills work decently, IV Tylenol anecdotally seems to work great for some people. The IV route ensures rapid action and onset of pain control. However, studies seem to be mixed on whether or not IV Tylenol provides superior pain control to PO Tylenol, and this systematic review suggests no clear indication for prescribing IV over PO – at least when the patient is able to tolerate oral. But even oral Tylenol is also a valid opioid alternative and has been shown to be effective for many types of pain – especially as an adjunct.
Ofirmev does not have a generic brand as of yet, so it tends to be expensive. However, this is cheaper than it used to be. The cost of 1gm of Ofirmev (standard dose) is $57, while 1gm of PO Acetaminophen is less than $1 – so cost is still something to consider. For repeated dosing, if the patient can tolerate PO Tylenol – you should probably try that (or risk getting yelled at by your hospital pharmacist).
KETOROLAC (IV/IM TORADOL)
Ketorolac (Toradol) is a staple in the Emergency department. We often give it when we suspect musculoskeletal causes of pain, when the patient has an orthopedic injury or surgery, or if the patient has renal colic. Toradol can be given in both IM and IV routes. Common dosages are 60mg for IM, and 15-30mg for IV. This is an NSAID – basically the equivalent of IV ibuprofen, so those who are allergic to NSAIDs or those with GI bleeds or significant cardiac disease should probably get something else to be on the safe side. A common misunderstanding is that IV Toradol is safe to give for those with upper GI bleeds or Gastritis since its IV, but the action of Toradol still inhibits prostaglandin synthesis and can lead to stomach irritation and decreased renal perfusion.
Interestingly enough, it’s possible IM Toradol hasn’t been shown to be more effective for pain control over PO ibuprofen in ER patients . The IV route, however, does offer a more rapid onset of action. I personally think patients seem to think that IV or IM routes offer better relief, and if an IV is already being ordered why not try an IV dose. When used at appropriate doses, side effects from a one-time dose are rare. If present, they can cause dizziness, nausea, or headaches.
Traditionally 30mg was used for IV dosing, however, this Randomized control trial indicates that IV doses at 10, 15, and 30mg all offered similar pain relief. I usually just order 15mg IV when using this med IV, especially to geriatric patients.
Similar to Toradol, Lidocaine can be useful for both musculoskeletal and renal colic – just in different forms. Lidocaine topical patches are often used for musculoskeletal pain from a muscle strain or chronic back pain. A Cochrane meta-analysis indicated that there was “some indication that topical lidocaine offered benefit”, specifically for neuropathic pain, but the trials were poor. Even so, it is often used because of the high safety profile and the limited adverse reactions due to lack of significant systemic absorption.
5% lidocaine patches should be placed on the most painful area and left for 12 hours. Up to 3 patches can be used at the same time if needed for a large area. When prescribing, brand Lidoderm patches can be expensive at approximately $24 per patch. Without insurance – this is clearly an issue as a 30 count is > $600. A cheaper option is to prescribe 4% lidocaine cream which is about $30 for a month’s supply.
IV Lidocaine has traditionally been used as an antiarrhythmic for dangerous ventricular cardiac arrhythmias like VTACH or VFIB. However, IV lidocaine has also been shown to offer significant pain relief for various types of pain including neuropathic pain and renal colic ,. The normal dose is 1.5mg/kg (max 200mg) given slowly over 10 minutes. Cardiac monitoring should be applied during and for 30-60 minutes after the infusion. If given, it should probably be combined with IV Toradol for adjuvant therapy if able to tolerate it. Contraindications include:
- Allergy to Lidocaine
- History of seizures
- Actively Pregnant
- Hepatic or Renal Failure
- Severe CAD, heart block, or arrhythmia
If any serious reaction like seizures or cardiac arrhythmia does occur – intralipid emulsion therapy is the treatment, and this should be readily available in case it is needed – although side effects at the normal dose are rare, with mild transient dizziness being the most common.
Cyclobenzaprine (Flexeril) is another opioid alternative for musculoskeletal pain, specifically involving the muscles. If there is any type of muscle strain – Flexeril can help relax the muscles and offer some pain relief. This is usually not used alone, but in conjunction with Tylenol, or an NSAID like Ibuprofen/Naproxen. Flexeril should usually be used as a short-term treatment for muscle strains or back pain. Although overall safe, they do have some side effects including sedation, so the patient needs to be able to tolerate this effect and be sure not to drive or work under the influence of Flexeril. Be wary when combining with opioids as they can compound the sedation and risk respiratory depression (Narcan anyone?)
Other Opioid Alternatives
There are multiple other specific treatments for pain depending on the source. Reglan works directly on migraine-pain, Pyridium works for bladder pain from UTIs, and even low-dose Ketamine can be used for chronic and perioperative pain. There is also a multitude of non-pharmacologic pain management techniques including heat or cryotherapy, massage, acupuncture, or even guided imagery (never have I ever seen this be a valid option within the hospital).
These opioid alternatives are not a reason not to give appropriate analgesia to patients in pain. Patients experience real and debilitating pain every day, and opioids are one of our tools to provide them with some relief and aid in their healing. Oftentimes non-narcotic analgesics can be great adjuncts to supplement opioids, or at least a reasonable first step prior to “stepping up” to meds like morphine, Dilaudid, or fentanyl. As always, use your clinical judgment and always advocate for your patients.
- Derry, S., & Moore, R. A. (2014). Topical lidocaine for neuropathic pain in adults. Cochrane Database of Systematic Reviews. https://www.ncbi.nlm.nih.gov/pubmed/25058164
- Firouzian, A., Alipour, A., Rashidian Dezfouli, H., Zamani Kiasari, A., Gholipour Baradari, A., Emami Zeydi, A., Amini Ahidashti, H., Montazami, M., Hosseininejad, S. M., & Yazdani Kochuei, F. (2016). Does lidocaine as an adjuvant to morphine improve pain relief in patients presenting to the ED with acute renal colic? A double-blind, randomized controlled trial. The American Journal of Emergency Medicine, 34(3), 443-448. https://www.ncbi.nlm.nih.gov/pubmed/26704774
- Jibril, F., Sharaby, S., Mohamed, A., & Wilby, K. J. (2015). Intravenous versus oral acetaminophen for pain: Systematic review of current evidence to support clinical decision-making. The Canadian Journal of Hospital Pharmacy, 68(3). https://www.ncbi.nlm.nih.gov/pubmed/26157186
- Knight, C. L., Deyo, R. A., Staiger, T. O., & Wipf, J. E. (2020). UpToDate. T. W. Post (Ed.). UpToDate. https://www.uptodate.com/contents/treatment-of-acute-low-back-pain
- Motov, S., Yasavolian, M., Likourezos, A., Pushkar, I., Hossain, R., Drapkin, J., Cohen, V., Filk, N., Smith, A., Huang, F., Rockoff, B., Homel, P., & Fromm, C. (2017). Comparison of intravenous ketorolac at three single-dose regimens for treating acute pain in the emergency department: A randomized controlled trial. Annals of Emergency Medicine, 70(2), 177-184. https://www.ncbi.nlm.nih.gov/pubmed/27993418
- Neighbor, M. L., & Puntillo, K. A. (1998). Intramuscular ketorolac vs oral ibuprofen in emergency department patients with acute pain. Academic Emergency Medicine, 5(2), 118-122. https://www.ncbi.nlm.nih.gov/pubmed/9492131
- Soleimanpour, H., Hassanzadeh, K., Vaezi, H., EJ Golzari, S., Esfanjani, R. M., & Soleimanpour, M. (2012). Effectiveness of intravenous lidocaine versus intravenous morphine for patients with renal colic in the emergency department. BMC Urology, 12(1). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3508963/