The Future of Pain Management

It seems like just a few years ago pain management became a key issue that we were working on in out-of-hospital patient care. The National Association of EMS physicians published its position paper 15 years ago suggesting we better identify and treat pain in the field. There was an epidemic of untreated pain, and opioids were the solution. Now the conversation is changing again, with mandates from many government organizations we are faced with the challenge of continuing to treat our patients’ pain but reduce the use of opioids.

But what medications do we have to replace opioids? Ketorolac has been a popular in-hospital medication and in many states has been in the EMS protocol for some time, but is it a replacement for opioids? With rather simple dosing and availability it seems like an ideal candidate. Although research is mixed, opioids appear to be better for the severe pain we typically treat in EMS. It certainly gives us an option for less severe pain or in cases such as migraines where NSAIDs are more effective.

What about the use of acetaminophen PO or IV? Although these are great choices and have been shown to be very successful analgesics in the right setting, they typically would not be used on patients who would normally require opioids for pain management. With PO acetaminophen offering some other advantages such as fever reduction and a pain management solution for BLS, the addition to EMS protocols appears well founded, but does not serve as a substitute for opioids. As for IV acetaminophen, there is some compelling evidence for its use in reducing severe pain but with limited manufacturing this might not be a solution for the entire EMS community.

One interesting choice here is Ketamine. Many of us already have access to it for other conditions such as for psychiatric patients requiring sedation or for airway management. It has been used for many years in the military for pain and sedation.  Its great safety profile is one element that helped move it into our med box to begin with. In one medication, we get the benefit of both pain relief and sedation, but without the hypotension and respiratory depression we see in our other treatments. It would seem that the next evolution in pain management is most likely going to involve the use of Ketamine.

With any major change, we must be able to measure its success. There are two primary ways to do this, we look at overall reduction of pain as a metric to measure the success of any analgesic. This can certainly be done with the EMS data that we collect now and would involve us evaluating the success in pain reduction of fentanyl or morphine versus that of ketamine or even IV acetaminophen. We can also look at patient satisfaction survey results to see if there is any noticeable change in patient’s perception of their treatment and pain reduction.

Regardless of your agency’s current practice for pain management and what medications you have available to you, it is nearly certain that we will soon see drastic changes in how we manage pain in the pre-hospital environment.

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