Noninvasive New Frontiers for Pain Control in EMS

Abstract

Noninvasive forms of pain control present unique opportunities to EMS clinicians of all levels. They can allow providers that have never previously had pharmacological methods for pain control the capability to begin pain management before advanced-level care arrives or a patient is brought to the emergency department. Even for advanced providers, noninvasive pain control presents several benefits. These forms of noninvasive pain control can be initiated much quicker than other forms of pain control, which require time-intensive preparation. For the advanced provider, noninvasive pain control might be a good first step before more-traditional forms of pain therapy are deployed. Regardless of the specific use-case, EMS departments and other agencies that provide emergency medical care would be benefited by examining if noninvasive forms of pain control might have a role in how they respond to requests for service that involve pain.

Introduction

In 2002, Borland and colleagues wrote “prehospital analgesia is an area worthy of innovative methods for the administration of safe and effective analgesics without significant impact on transport times”.¹ Written statements in research journals have, in the past, proven to be persuasive tools in advocating for new types of interventions.² Pain-related emergencies are some of the most common reasons individuals seek medical assistance in emergency departments, and estimates suggest that roughly one-third of emergency medical services (EMS) activations nationwide involve some form of pain.^3,4 Pharmacological therapies are commonly deployed in the prehospital setting for patients needing pain management.^5,6

Many credit the birth of prehospital pain control to the United Kingdom’s Baskett & Withnell (1970), who describe the use of a gaseous mixture of nitrous oxide and oxygen in 66 patients with severe pain over a three-and-a-half month period. In all patients, they report partial or total pain relief was achieved with no adverse effects experienced.⁷ Just a few years later, their gaseous mixture was commonly-used in the prehospital setting.⁸ Since then, other methods of pain control have been adopted by EMS agencies.

Related

• A Guide to Prehospital Pain Management
• Prehospital Pain Management
• Using Nitrous Oxide to Manage Pain

The main medication classes used for pain control in the prehospital include opiates, NMDA receptor antagonists, benzodiazepines, nonsteroidal anti-inflammatory medications, and non-opiate pain medications.⁴ Of these, opiates – such as morphine and fentanyl – are the most commonly-used.⁹ They are predominantly administered intravenously (IV) or intramuscularly (IM).⁴

Currently, pain control is considered by many to be a necessity on ambulances capable of operating at the advanced life support (ALS) level.¹⁰ Having said that, the main administration routes used for many forms of pharmacological pain therapies limit who are authorized to use them. Many providers are hindered by an inability to deliver high-potency pharmacological pain control, especially those that respond to 911 calls without timely access to advanced providers. However, it does not have to be this way. Pain management medications have been shown to be successfully delivered through alternative, less-invasive routes. Adding less-invasive routes of medication delivery might enable pharmacological pain control to be safely administered by a broader range of providers. For example, medications might be administered through a nasal spray, a buccal (cheek) tablet, via inhaled gas, or a skin patch.¹² These additional routes of pain control administration have the potential to improve patient care.

Transmucosal Opiates

Opiates are some of the most commonly administered medications used in the prehospital environment. They have been traditionally given intravenously or intramuscularly, and many have expressed concerns about the potential for fatal reactions following provider error – these considerations have meant that their use is not universal. Opioid medications can, however, be delivered transmucosally: one option has been a lollipop-style lozenge that can be placed in a patient’s mouth, while another option is the delivery of medication intranasally.¹⁴

Noninvasive opioids present several advantages when compared to traditional opioid administration. Unlike with doses delivered intravenously or intramuscularly, transmucosal opioids delivered through a lollipop specifically can be titrated based on effectiveness or any adverse reactions. For instance, if a provider notices the patient is experiencing decreasing levels of alertness, they can remove the delivery device before a dangerous reaction happens and provide opioid reversal if needed. The use of oral transmucosal fentanyl citrate has been well-documented in military settings, as well as in pediatric patients.^15-18

The delivery of medication intranasally has been widely studied in the emergency environment, and this route of drug delivery is effective because of the highly-vascularized and communicative nature of the tissues lining the nasal pathway.¹⁹ One of the main benefits of intranasal pain medication administration is decreases in the time needed to administer the medication. One study directly comparing intravenous opioids with intranasal opioids in the emergency department setting found patients were able to be given intranasal fentanyl much faster than intravenous opioids, and there was no significant difference in the number of adverse effects between groups.²⁰ Another study tested intranasal fentanyl in pediatric patients treated by EMS, finding the drug “appears to be a safe and effective analgesic in the prehospital management of acute severe pain in children and may be an attractive alternative to both oral and intravenous opiates”.²¹

Considerations for BLS Providers

The ease of deployment associated with noninvasive pain medications means that non ALS-level units – including BLS-equipped ambulances, non-transporting fire apparatus, and law enforcement – could initiate effective pain control prior to the arrival of ALS-level units or before the patient is brought to an emergency department. In communities with limited ALS-level resources, noninvasive pain control administration by BLS units might reduce workload on ALS units and reduce the amount of time a trauma patient might experience intense pain. The successful deployment of noninvasive pain control at the BLS level is dependent on adequate training and, in the case of potent opioids, the ability to quickly reverse any unwanted effects of the medication if the need arises. Of course, providers should also be trained on the pharmacodynamics of the medications, as well as specific indications and contraindications.

Additional Pain Management for ALS Providers

Even though the main attraction of noninvasive pain control might be its use by non-advanced providers, noninvasive forms of pain management might still have the potential to play a unique role in ALS-level care. Preparing many current forms of pain control may require providers to spend significant time drawing up medication, ensuring they have the correct dosage, preparing administration equipment, and obtaining intravenous or intraosseous access (in some cases). Noninvasive pain control might be able to be initiated and provide relief to the patient while other forms of pain control are being prepared. Alternatively, noninvasive pain control might be used in situations where large amounts of medication are not needed or in “load-and-go situations” where spending time establishing vascular access is not in the patient’s best interests.

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Conclusions

Forms of noninvasive pain control present interesting benefits for EMS providers at multiple levels. First, their ease-of-use might allow their use by providers who previously did not have access to pharmacologic methods of pain control. Second, these same properties might make them valuable additional tools to advanced providers who may choose to use them over more-invasive forms of pain control in specific situations. Further study, such as a prospective clinical trial comparing current versus noninvasive forms of pain control, would likely provide additional compelling evidence for their adoption.

References

1. Borland ML, Jacobs I, Rogers IR. Options in prehospital analgesia. Emergency medicine. 2002 Mar;14(1):77-84.
2. Braude D, Richards M. Appeal for fentanyl prehospital use. Prehospital Emergency Care. 2004 Oct 1;8(4):441.
3. Chang HY, Daubresse M, Kruszewski SP, Alexander GC. Prevalence and treatment of pain in EDs in the United States, 2000 to 2010. The American journal of emergency medicine. 2014 May 1;32(5):421-31.
4. Schwerin DL, Mohney S. EMS, Pain Assessment And Management. StatPearls [Internet]. 2020 Feb 20.
5. Lord B. The Paramedic’s Role in Pain Management: A vital component in the continuum of patient care. AJN The American Journal of Nursing. 2004 Nov 1;104(11):50-3.
6. Lord B, Nicholls T. A brief history of analgesia in paramedic practice. Journal of Paramedic Practice. 2014 Aug 2;6(8):400-6.
7. Baskett PJ, Withnell A. Use of Entonox in the ambulance service. Br Med J. 1970 Apr 4;2(5700):41-3.
8. Chambers JA, Guly HR. The need for better pre-hospital analgesia. Emergency Medicine Journal. 1993 Sep 1;10(3):187-92.
9. Fleischman RJ, Frazer DG, Daya M, Jui J, Newgard CD. Effectiveness and safety of fentanyl compared with morphine for out-of-hospital analgesia. Prehospital Emergency Care. 2010 Jun 1;14(2):167-75.
10. American College of Emergency Physicians. Out-of-Hospital Use of Analgesia and Sedation. Ann Emerg Med. 2016;67(2):305-6.
11. Faddy SC, Garlick SR. A systematic review of the safety of analgesia with 50% nitrous oxide: can lay responders use analgesic gases in the prehospital setting?. Emergency medicine journal. 2005 Dec 1;22(12):901-8.
12. Smith JE, Russell R, Mahoney PF, Hodgetts TJ. What is the ideal pre-hospital analgesic?–A questionnaire study. BMJ Military Health. 2009 Mar 1;155(1):44-6.
13. Amey BD, Ballinger JA, Harrison EE. Prehospital administration of nitrous oxide for control of pain. Annals of emergency medicine. 1981 May 1;10(5):247-51.
14. Mystakidou K, Katsouda E, Parpa E, Vlahos L, Tsiatas ML. Oral transmucosal fentanyl citrate: overview of pharmacological and clinical characteristics. Drug Delivery. 2006 Jan 1;13(4):269-76.
15. Robert R, Brack A, Blakeney P, Villarreal C, Rosenberg L, Thomas C, Meyer III WJ. A double-blind study of the analgesic efficacy of oral transmucosal fentanyl citrate and oral morphine in pediatric patients undergoing burn dressing change and tubbing. The Journal of burn care & rehabilitation. 2003 Nov 1;24(6):351-5.
16. Kotwal RS, O’Connor KC, Johnson TR, Mosely DS, Meyer DE, Holcomb JB. A novel pain management strategy for combat casualty care. Annals of emergency medicine. 2004 Aug 1;44(2):121-7.
17. Blackbourne LH, Baer DG, Eastridge BJ, Butler FK, Wenke JC, Hale RG, Kotwal RS, Brosch LR, Bebarta VS, Knudson MM, Ficke JR. Military medical revolution: military trauma system. Journal of Trauma and Acute Care Surgery. 2012 Dec 1;73(6):S388-94.
18. Wedmore IS, Kotwal RS, McManus JG, Pennardt A, Talbot TS, Fowler M, McGhee L. Safety and efficacy of oral transmucosal fentanyl citrate for prehospital pain control on the battlefield. Journal of Trauma and Acute Care Surgery. 2012 Dec 1;73(6):S490-5.
19. Bailey AM, Baum RA, Horn K, Lewis T, Morizio K, Schultz A, Weant K, Justice SN. Review of intranasally administered medications for use in the emergency department. The Journal of emergency medicine. 2017 Jul 1;53(1):38-48.
20. Schaefer JA, Mlekoday TJ. Time to opioid administration after implementation of an intranasal fentanyl protocol. The American journal of emergency medicine. 2015 Dec 1;33(12):1805-7.
21. Murphy AP, Hughes M, Mccoy S, Crispino G, Wakai A, O’Sullivan R. Intranasal fentanyl for the prehospital management of acute pain in children. European Journal of Emergency Medicine. 2017 Dec 1;24(6):450-4.