A Laughing Matter: Kentucky Service Tries Nitrous Oxide Instead of Opioids for Pain

McCreary County is a beautifully scenic area in southeastern Kentucky, with much of its territory occupied by the Daniel Boone National Forest and the Big South Fork National River and Recreation Area. But although this rural jurisdiction of 463 square miles is home to just 17,465 residents (plus many tourists passing through), the growing opioid epidemic has not left McCreary County untouched.

“Like everywhere else, the opioid overdose situation here is horrible and getting worse,” says Chief Jimmy Barnett, director of the McCreary County Ambulance Service (McCreary County EMS), based in Whitley City. McCreary County EMS has a total of six ambulances and 4–5 crews doing both emergency and nonemergency transports every day, for a total of 4,500–4,800 transports a year.

“In this small town and the surrounding county, we don’t have a hospital,” Barnett says, “so when we do have an opioid overdose, our EMS crews have to drive 20–30 miles to get the patient to the nearest hospital for treatment. This can have a negative impact on patient care.”

To complicate matters further, McCreary County EMS doesn’t like to give opioid-based painkillers to accident victims, just in case they might already be overdosing on such drugs. “If we do give patients painkillers, we could be compounding their problem,” says Barnett. “Likewise, if they are trying to get off opioids and using Narcan as part of that process, then giving them opioids won’t work to lessen pain.”

Add the fact that McCreary County’s advanced EMTs aren’t authorized to administer opioids to patients (their paramedics can), and one can see why Barnett has been looking for a pain-reduction option that avoids the many issues associated with opioids.

The one he’s found is nitrous oxide—‘laughing gas.’

Each McCreary County EMS ambulance has now been equipped with a “nitronox field unit” sold by Henry Schein Medical. Housed in a wearable shoulder bag, each unit can provide up to one hour’s worth of nitrous oxide-based pain relief to a patient without resorting to opioid-based painkillers.

“We are the first county in Kentucky to carry nitrous oxide in our ambulances,” says Barnett. “Once other counties see how well nitronox works in pain management, we expect they will follow our lead.”

The Magic of Laughing Gas

According to the American Dental Association, “Nitrous oxide is a safe and effective sedative agent that is mixed with oxygen and inhaled through a small mask that fits over your nose to help you relax… Ultimately you should feel calm and comfortable. The effects of nitrous oxide wear off soon after the mask is removed.”

Known for its euphoric effects, nitrous oxide doesn’t so much relieve pain as it makes enduring pain easier. “It’s more of a sedative than a painkiller,” says Barnett. “Nitrous oxide doesn’t take the pain away, but it makes you care less that you have it.” He noted that nitrous is effective for 95% of the population. “No one knows why the other 5% don’t respond to it,” he says.

“Another big advantage to nitrous oxide is that it acts quickly, taking effect within 1–3 minutes,” adds Assistant Chief Brandi Kidd. “The effects of nitrous are also short-acting: It lasts 3–5 minutes; then the patient is coherent and able to answer questions. In contrast, opioid pain medications leave the patient altered for an extended amount of time.”

Deployment

The nitronox field units now carried by McCreary County ambulances each consist of a pair of small oxygen and nitrous oxide bottles, a mixing tank with pressure gauge and flow control, a hose, and a mask that covers the patient’s nose and mouth.

“The field unit premixes the oxygen and nitrous oxide 50/50,” says training officer Kasey Phillips. “You just put the mask on the patient, open up the flow control, and that’s it.”

“We just deployed the units to our ambulances, now that we’ve been able to get extra tanks on standby from our supplier,” Phillips adds. “We didn’t want to risk our crews running out of nitrous oxide in the field by not having spare tanks at hand. Now when we run low, our supplier can get fresh tanks straight to us.”

Henry Schein Medical provided nitronox training to every McCreary County EMS member, ensuring the units can be used no matter who’s on shift.

“If a paramedic is out of town on a transfer and an ambulance is being staffed by an advanced EMT, they now can administer pain relief to patients,” says Barnett. Notes Kidd, “We’ll be able to provide better patient comfort in all instances as a result.”

The best news is that the nitronox field units are inexpensive to keep topped up with oxygen and nitrous oxide. “Even when you factor in the cost of refilling the bottles and replacing the mask, the cost is less than $6,” Kidd says. “That’s less than what we would pay for an opioid-based painkiller to perform the same function.”

The team at McCreary County EMS is proud to be the first agency in the state to be approved to use nitrous oxide. But they don’t expect to hold on to this exclusivity for long.

“We’ve been getting lots of calls from other EMS departments,” says Barnett. “I think nitrous oxide is going to be really big in Kentucky and other states, what with the drug problems we’re all dealing with.”

James Careless is a freelance writer and frequent contributor to EMS World.