A paramedic injecting a medication. (Photo/A.J. Heightman)

The Now and the Future of Pain Control in the Prehospital Arena

In light of the pervasive “Opioid Crisis,” medical practitioners are increasingly expected to consider the potential use of non-narcotic methods of pain control for patients.  To explore this, a survey of an international cohort of EMS medical directors assessed the provision of opiate and non-opiate pain control medications.  Injectable opioid medications were much more commonly used than non-opioid medications for pain control, in part a result of the price of the non-opioid medications.  The authors suggest a need for further consideration of alternatives to injectable opiates for the control of pain in the prehospital field.

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Introduction

The “Opioid Crisis” has proven to be the worst drug-related epidemic the United States has faced, with markedly greater drug overdose deaths than the previous Heroin and Cocaine epidemics.1  In 2016 the US suffered from 63,632 overdose deaths, an increase of 21.4% from 2015, two thirds involving opioids.2  This comes to approximately 116 Americans killed per day from both prescription and illicit opioid overdose, and that number continued to rise into 2017.1 

Shockingly, despite comprising a mere 4.6% of the world’s population, Americans consume an estimated 80% and 99% of the prescription opioid and hydrocodone global supplies respectively,3-6 a vast level of consumption that has left few US demographics unscathed.7 These numbers include more than 54,000 pregnancies complicated by opioid dependency each year,8-9 and adolescents involved in competitive sports that have been found to be at a greater risk for misuse of prescribed medical opioids.7,10,11

Standards of ethical duty require medical providers to use the tools they have available to relieve their patients’ suffering.  Yet despite providing an often medically necessary analgesic effect, opioid administration may be associated with the additional burdens of abuse, addiction, hyperalgesia, overdose, aspiration, pneumonia, cardiovascular events, and death.12  These opioid-associated adverse events come with a heavy financial toll, with a 47% increase in health care costs and a 36% increased risk of readmission for patients receiving a common surgical procedure between the years 2009 and 2010.7,13  Neonatal Abstinence Syndrome (NAS) alone has cost hospitals $1.5 billion, with most of that cost being passed onto state Medicaid programs.14 

The nondiscriminatory, costly, and profoundly impactful nature of this epidemic has led to widespread scrutiny of many healthcare fields and strong governmental engagement.  Numerous federal agencies including the Drug Enforcement Agency (DEA), Department of Justice (DOJ), Food and Drug Administration (FDA), and the Centers for Disease Control (CDC) have established guidelines in an effort to stem the toll of the thousands of deaths a year from prescription and nonprescription opioids.15

The roots of the opioid crisis cannot be traced back to a single origin. Issues specific to the pharmaceutical industry, to physicians of various specialties, and to other related entities each contributed in part to the insidious growth in opioid use.7  Included in this group – though whose role has not been widely examined – is the area of prehospital care provided by emergency medical services (EMS).  EMS providers in the field, working under medical direction protocols, commonly administer opioid analgesics such as morphine, fentanyl, and hydromorphone to manage acute pain.

As with the care rendered to patients in emergency departments, opioids administered by EMS providers are given during the episodes of patient care only and not for chronic administration. Thus, it is unclear what role EMS opioid administration plays in the opiate epidemic broadly.  Regardless, best practices require EMS providers to provide effective and compassionate care to patients in distress from acute pain, and opioid administration is certainly appropriate in such cases. 

Regardless, it is prudent for EMS providers to also consider the wider context and potential long-term impact that any opioid administration may have, and thus the possibility of nonopioid analgesic alternatives for prehospital care must be examined.

The available research on the efficacy of various pain control drugs, specifically in the EMS setting, is limited.  A recent meta-analysis compared the analgesic efficacy between intravenous (IV) opioids including morphine and fentanyl to IV non-opioids including acetaminophen (paracetamol), ketamine, and non-steroidal anti-inflammatories (NSAIDs) such as ketorolac and ibuprofen in the emergency department environment.16 

The researchers found no significant difference between the analgesic effects of IV opioids, ketamine, paracetamol, and NSAIDs.16  A randomized controlled study compared the analgesic effectiveness of IV hydromorphone to IV acetaminophen administration in the emergency department.  It was found that while IV hydromorphone provided statistically significant greater pain reduction compared to IV acetaminophen, both were clinically meaningful.17  However, the additional pain relief from hydromorphone came with a greater incidence of side effects, including nausea and vomiting. 17

The authors of the present study desired to estimate the utilization of IV acetaminophen in the prehospital arena to determine if a non-opiate intravenous method of pain control has become a widely utilized option, and to determine what might be limitations to the proliferation of this analgesic in EMS systems.

Methods

To assess the utilization of intravenous paracetamol/acetaminophen compared to other opioid and non-opioid pain control medications in the prehospital setting, an international survey was distributed to members of the Metropolitan Urban EMS Medical Directors Coalition (the “Eagles”), an international association of EMS Medical Directors of large urban EMS systems who collectively provide prehospital care to over 120 million lives. 

The directors were questioned on their departments’ policies and practices regarding prehospital pain control.  Specifically, the authors wanted to know if the EMS agencies provided injectable opiates for pain control. 

A question was included about the use of injectable or intranasal ketamine for analgesia.  The survey contained questions about the use of oral pain medications such as acetaminophen, aspirin, and ibuprofen.

Attention was then directed to the use of non-opiate injectable analgesics such as paracetamol, ketorolac, and ibuprofen.

Finally, the respondents were asked what factors may have affected a given decision for what medications to be provided for pain control, including cost, efficacy, and route of administration.  The survey questions are found in Table 1 below.

Table 1. Prehospital Pain Control Survey Questions to EMS Medical Directors

Results

Fifty-six survey responses were received.  The majority of responses were from medical directors of EMS departments in the United States, but there were also responses from The Netherlands and the United Kingdom. 

Of the 55 departments that included these medications, 26 (47%) reported including Morphine, 4 (7%) reported including Hydromorphone, 52 (95%) reported including Fentanyl, and 33 (60%) reported including Ketamine.

Thirty-two (58%) of respondents reported including non-opiate injectables in their protocols. Of the 24 departments that did include non-opiate injectables, 16 (67%) reported including ketorolac, and 6 (25%) reported including paracetamol.

Thirty-two (57%) of respondents denied including oral pain control medications in their protocols. Regarding the reasons for choice of specific analgesics, 24 (43%) of respondents cited the cost of medications as playing a role in determining their departments’ protocols.  Forty (71%) cited medication efficacy as important, and 38 (68%) cited route of administration as playing a key role.

Discussion

Patients experiencing acute pain in the prehospital arena require the attention and care of EMS professionals to manage this condition.  A spectrum of therapies is available to the provider for the treatment of pain, ranging from the splinting of fractures (which is known to reduce the level of pain from an acute fracture) to the use of medications. 

Medications to treat pain may be administered in a variety of ways, including oral, intranasal, intramuscular, intravenous, and rectal, and the choice of medication and route of administration may vary based upon an important set of parameters.  These parameters include severity of pain, medications allergies, route of administration, and cost of the medication(s).

The impact of opiate addiction – including the deaths from opiate overdose – cannot be overstated.  Increasing scrutiny of the prescribing of opiates is emerging, ranging from prescription monitoring programs and their mandatory checking by prescribers to limiting the amount of opiate medication that can be prescribed as outpatients for patients discharged from emergency departments. 

It would seem prudent to avoid the utilization of opiates altogether when possible, and the provider should consider a non-opiate alternative when patient condition permits.  Unfortunately, limiting the movement toward non-opiate injectable medication is the high cost of some of the choices. 

Recent scientific evidence has shown that injectable paracetamol is an effective choice for pain control that approaches the efficacy of intravenous hydromorphone with fewer side effects. 17 However, the cost of injectable paracetamol in America – as opposed to other countries – has been one of the limiting factors in the wider adoption of this medication in EMS systems across the country.  The authors wished to assess whether the cost of this medication is a significant factor that is limiting the utilization of this method of pain control.

This survey revealed that the cost of injectable paracetamol is indeed a significant limiting factor to its widespread adoption in America by EMS systems for pain management in the field.  Whereas the cost of a 1000 mg unit of injectable paracetamol in England is approximately 60 cents, or approximately $3 in Australia (18), that same unit of injectable paracetamol the United States may cost as much as $42 (checked online March, 2020). 19  Thus, the cost of this medication by this route of administration is a substantial disincentive to its implementation in EMS systems in America, according to the poll conducted by the authors. 

The data from this poll indicates that a significant reduction in the cost of this particular pain medication could result in its becoming one of the “go to” injectable pain medications used by EMS systems, resulting in perhaps millions of administrations for pain control per year rather than a much lower utilization.

Conclusion

Patients experiencing acute pain in the field are commonly managed by EMS providers.  EMS medical directors must weigh a broad set of issues as they establish the protocols for the treatment of pain within their systems.  In collaboration with EMS system management, the medical director must examine what treatment options are to be made available, by what route, and at what cost, consistent with the resources available to the system.

References

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