Guest Editorial: Don’t Let the Opioid Furor Cloud Your Judgment

From the EMS point of view, patients experiencing nontraumatic pain have been too often overlooked. It may seem obvious that a broken bone is painful; however, abdominal pain and headaches without obvious distress present prehospital providers with a dilemma: to empathetically treat the patients’ reported pain at risk of perpetuating the opioid epidemic, or to prevent harm associated with downstream effects of opioid administration while allowing patients to suffer.

While research has demonstrated that both emergency department and prehospital providers undertreat pain, especially in certain populations such as minorities and women, prehospital education has failed to equip providers with strategies to treat pain effectively. 

Unfortunately, pain is a subjective experience, and the pain scale is not truly “one size fits all.” Many people perceive pain differently due to a variety of physical, psychological, and social factors. In the same way that some people hear “Laurel” while others hear “Yanny” despite the same sound waves hitting their eardrums, some may perceive as excruciating what others experience as mild pain. 

Additionally, patients have different expectations and goals related to pain management. For example, some opiate-naïve patients adhere to a philosophy of avoiding opiates at all costs for fear of initiating addiction. In a time when public awareness of the current opioid crisis has reached an all-time high, competing pressures of treating pain appropriately and avoiding the use of opiates have come into conflict.

The downstream effects of the opioid crisis, namely the expressive public face of addiction and rising overdoses and withdrawal, force prehospital providers to carefully consider utilization of opiate pain medications. Especially problematic is the fabled “pill seeker,” who is deemed to be faking or embellishing a complaint to get narcotics.

Although these patients exist, the pervasive culture of doubting patients’ pain has been born from the opioid crisis and the burden it has placed on EMS providers in terms of call volume and compassion fatigue. It often creates an “us vs. them” mentality with our patients, which is counterproductive and unfair to patients experiencing pain.

In general, current EMS protocols for pain management follow a very simple algorithm: Determine the level of pain (or apparent level of pain based on the providers’ biases), categorize to “mild” or “moderate/severe,” then give the “mild” pain group OTC analgesics or the “moderate/severe” group ketorolac or the agency’s narcotic of choice.

The footnotes then exclude patients who might need surgical intervention, such as patients with headaches, fractures, or abdominal pain, from receiving oral analgesia. Often, the only option left for a large portion of patients is parenteral narcotics. 

Picture the middle-aged patient who calls EMS for a 10/10 headache, curled up in a dark room, feeling so miserable they can’t even look you in the eyes to provide a history. You follow the protocols as best you can, quickly proceeding down the “severe” arm, skipping ketorolac because this could potentially be a subarachnoid hemorrhage, giving 1 mg of hydromorphone and adding ondansetron for the nausea. You take the patient uneventfully to the ED with pain now improved to 9/10.

Now imagine a protocol based on the evidence for dopamine antagonists, particularly prochlorperazine. Two recent trials were stopped early due to its clear superiority over both ketamine and hydromorphone in the treatment of headaches. In one study 85% of patients reported mild to no headache one hour after receiving prochlorperazine, compared to 52% of patients who received hydromorphone.

Similarly, in a randomized trial of haloperidol versus placebo, 80% of patients randomized to haloperidol had mild to no headache 1–3 hours after receiving the medication. In an open-label component of the same study, 79% of patients receiving haloperidol noted mild to no headache 1–3 hours after infusion. The “one size fits all” pain management protocols clearly do not fit all pain. 

Similar data exists for treatment of gastroparesis, showing significant reduction in pain and nausea when 5 mg of haloperidol is added to routine ED treatment. Another study showed decreased use of morphine and decreased hospital admissions for patients with gastroparesis who received haloperidol. For pain from traumatic injury, ketamine has been shown to have a synergistic effect with morphine, offering better analgesia than repeat doses of morphine.

EMS providers and medical directors need to review our own practices. We should check our attitudes at the door and understand that our patients’ perceived pain may be more than we realize. We should update our protocols where evidence exists for symptom-specific treatments.

The combination will allow us to work with our patients, reduce the administration of narcotics, and more effectively control pain. 

For more on professional strategies to combat the opioid epidemic as well as community and healthcare resources that can help, see “Put Down the Pills” in this issue.

Benjamin Smith, MD, is assistant professor in the department of emergency medicine at the University of North Carolina School of Medicine in Chapel Hill, N.C. The author wishes to acknowledge Jane Brice, MD, and Christopher Cunningham, BS, for their assistance with this editorial.