Opioid free regimens: Difference between revisions

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Background:
==Background==
- The shift in pain management from a symptomatic approach to a mechanistic approach has allowed providers to address pain in a more targeted and efficient manner. By recognizing the pain receptors that are the culprit behind a patient’s symptoms, a higher level of care can be administered.
*The shift in pain management from a symptomatic approach to a mechanistic approach has allowed providers to address pain in a more targeted and efficient manner
*By recognizing the pain receptors that are the culprit behind a patient’s symptoms, a higher level of care can be administered


Pharmacologic Options:
==Pharmacologic Options==
* Below are a series of recommendations outlined by Dr. Sergey Motov and Dr. David Lyness.  
Below are a series of recommendations outlined by Dr. Sergey Motov and Dr. David Lyness. <ref>*Lyness, D., & Motov, S. (2016, July 7). CERTA Opioid Alternatives and Analgesics. Retrieved July 25, 2016, from http://www.propofology.com/infographs/certa-opioid-alternatives-as-analgesics</ref>


Abdominal Pain (non traumatic)
===[[Abdominal Pain]] (Non Traumatic)===
* IV Ketorolac 10-15 mg or IV Diclofenac 75 mg or IV Metimazole
*IV [[Ketorolac]] 10-15 mg or IV [[Diclofenac]] 75 mg or IV [[Metimazole]]
* IV Acetaminophen 1g over 15 minutes
*IV [[Acetaminophen]] 1g over 15 minutes
* IV Lidocaine 1.5 mg/kg of 2% over 10-15 minutes
*IV [[Lidocaine]] 1.5 mg/kg of 2% over 10-15 minutes
* IV Ketamine 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour
*IV [[Ketamine]] 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour


Abdominal Pain (traumatic)
===[[Abdominal Pain]] (Traumatic)===
* IV Acetaminophen 1g over 15 minutes
*IV [[Acetaminophen]] 1g over 15 minutes
* IV Ketamine 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour
*IV [[Ketamine]] 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour


Back Pain (nonradicular)
===[[Back Pain]] (Nonradicular)===
IV Ketorolac 10-15 mg or Ibuprofen 400 mg PO or IV Diclofenac 75 mg or IV Metimazole 1g
*IV [[Ketorolac]] 10-15 mg or [[Ibuprofen]] 400 mg PO or IV [[Diclofenac]] 75 mg or IV [[Metimazole]] 1g
Trigger point injection 10 ml 0.5% Bupivacaine or 20 ml of 1% Lidocaine
*Trigger point injection 10 ml 0.5% [[Bupivacaine]] or 20 ml of 1% [[Lidocaine]]
IV Acetaminophen 1g over 15 minutes
*IV [[Acetaminophen]] 1g over 15 minutes
IV Lidocaine 1.5 mg/kg of 2% over 10-15 minutes
*IV [[Lidocaine]] 1.5 mg/kg of 2% over 10-15 minutes
IV Ketamine 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour
*IV [[Ketamine]] 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour


Burns
===[[Burns]]===
IV Ketamine 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour
*IV [[Ketamine]] 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour
IV Lidocaine 1.5 mg/kg of 2% over 10-15 minutes, + continuous infusion at 1.5-2.5 mg/kg/hour
*IV [[Lidocaine]] 1.5 mg/kg of 2% over 10-15 minutes, + continuous infusion at 1.5-2.5 mg/kg/hour
IV Dexmedetomidine 02.-0.7 mcg/kg/hour drip  
*IV [[Dexmedetomidine]] 02.-0.7 mcg/kg/hour drip  
IV Clonidine 0.3-2 mcg/kg/hour drip
*IV [[Clonidine]] 0.3-2 mcg/kg/hour drip


Headache
===[[Headache]]===
IV Metoclopramide 10 mg (slow drip 10-15 minutes) or IV Prochlorperazine 10 mg (slow infusion)  
*IV [[Metoclopramide]] 10 mg (slow drip 10-15 minutes) or IV Prochlorperazine 10 mg (slow infusion)  
With IV Diphenhydramine 25-50 mg or IV Chlorpromazine 12.5 mg (slow infusion in 500 ml over 30 min - 1 hour)
*With IV [[Diphenhydramine]] 25-50 mg or IV Chlorpromazine 12.5 mg (slow infusion in 500 ml over 30 min - 1 hour)
SQ Sumatriptan 6 mg (within 1 hour of onset, 12 mg 1 hour later)
*SQ [[Sumatriptan]] 6 mg (within 1 hour of onset, 12 mg 1 hour later)
IV Ketorolac 10-15 mg or IV Diclofenac 75 mg or IV Metimazole 1 g
*IV [[Ketorolac]] 10-15 mg or IV Diclofenac 75 mg or IV Metimazole 1 g
US Guided nerve block, Paracervical trigger point injections with 2% Lidocaine or 0.5% Bupivacaine  
*US Guided nerve block, Paracervical trigger point injections with 2% Lidocaine or 0.5% Bupivacaine  
IV Haloperidol 2.5 mg, IV Droperidol 2-5 mg (slow infusion over 10 min)
*IV [[Haloperidol]] 2.5 mg, IV [[Droperidol]] 2-5 mg (slow infusion over 10 min)
IV Propofol (intractable migraine) 10 mg IVP q5 minutes
*IV [[Propofol]] (intractable migraine) 10 mg IVP q5 minutes
Refractory cases - Ketamine 0.2-0.3 mg/kg short infusion
*Refractory cases - [[Ketamine]] 0.2-0.3 mg/kg short infusion
MSK
US guided nerve block
IV Ketorolac 10-15 mg or IV Diclofenac 75 mg or IV Metimazole 1 g
IV Acetaminophen 1g over 15 minutes
IV Ketamine 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour


Neuropathic Pain
===MSK===
IV Ketamine 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour
*US guided nerve block
IV Lidocaine 1.5 mg/kg of 2% over 10-15 minutes, + continuous infusion at 1.5-2.5 mg/kg/hour
*IV [[Ketorolac]] 10-15 mg or IV Diclofenac 75 mg or IV Metimazole 1 g
IV Dexmedetomidine 02.-0.3 mcg/kg/hour IV infusion
*IV [[Acetaminophen]] 1g over 15 minutes
*IV [[Ketamine]] 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour


Renal Colic
===Neuropathic Pain===
IV Ketorolac 10-15 mg or IV Diclofenac 75 mg or IV Metimazole 1 g
*IV [[Ketamine]] 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour
IV Acetaminophen 1g over 15 minutes
*IV [[Lidocaine]] 1.5 mg/kg of 2% over 10-15 minutes, + continuous infusion at 1.5-2.5 mg/kg/hour
IV Lidocaine 1.5 mg/kg of 2% over 10-15 minutes
*IV [[Dexmedetomidine]] 02.-0.3 mcg/kg/hour IV infusion
IN Desmopressin 40 mcg once as adjunct to NSAID’s
*[[Gabapentin]] (not included in Motov/Lyness regimen)
IV Ketamine 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour
**Day 1: 300mg PO qDay
**Day 2: 300mg PO q12hr
**Day 3: 300mg PO q8hr


Sickle Cell Vaso-Occlusive Crisis
===[[Renal Colic]]===
IN Ketamine 1 mg/kg (no more than 1 ml per nostril)
*IV [[Ketorolac]] 10-15 mg or IV Diclofenac 75 mg or IV Metimazole 1 g
IV Ketamine 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour and SQ infusion at 0.15-0.25 mg/kg/hour
*IV [[Acetaminophen]] 1g over 15 minutes
IV/IM Haloperidol or Droperidol 5-10 mg
*IV [[Lidocaine]] 1.5 mg/kg of 2% over 10-15 minutes
IV Dexmedetomidine 02.-0.3 mcg/kg/hour continuous infusion
*IN [[Desmopressin]] 40 mcg once as adjunct to NSAID’s
*IV [[Ketamine]] 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour


Benefits:
===[[Sickle Cell Crisis]]===
The cycle of opioid abuse and addiction often arises with the first time administration of opioids in the ED for a variety of medical complaints. Limiting this exposure is one of the ways providers can help combat this epidemic.  
*IN [[Ketamine]] 1 mg/kg (no more than 1 ml per nostril)
A better understanding of underlying pain mechanisms will also likely result in overall improvement in pain management and satisfaction.  
*IV [[Ketamine]] 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour and SQ infusion at 0.15-0.25 mg/kg/hour
*IV/IM [[Haloperidol]] or [[Droperidol]] 5-10 mg
*IV [[Dexmedetomidine]] 02.-0.3 mcg/kg/hour continuous infusion


Feasibility:
==Benefits==
A recent study at Maimonides hospital designed an 8 hour opioid free ED shift that resulted in over 80% pain satisfaction scores at 30 and 60 minutes and no opioids used during the shift with just one opioid prescription written.  
*The cycle of opioid abuse and addiction often arises with the first time administration of opioids in the ED for a variety of medical complaints. Limiting this exposure is one of the ways providers can help combat this epidemic
*A better understanding of underlying pain mechanisms will also likely result in overall improvement in pain management and satisfaction
 
==Feasibility==
*A recent study being done at Maimonides hospital designed an 8 hour opioid free ED shift that resulted in over 80% pain satisfaction scores at 30 and 60 minutes and no opioids used during the shift with just one opioid prescription written<ref>The Opioid-Free ED: Coming Soon to a Hospital Near You. Medscape. Feb 28, 2015.</ref>


Weaknesses:
Weaknesses:
During above study, a challenge was managing staff that had little experience in using medications for off label uses.  
*During above study, a challenge was managing staff that had little experience in using medications for off label uses.  
Certain subsets of patients will have various contraindications that will need to be considered such as patients with cardiovascular disease and NSAIDs. Those contraindications will not be reviewed on this page.  
*Certain subsets of patients will have various contraindications that will need to be considered such as patients with cardiovascular disease and NSAIDs. Those contraindications will not be reviewed on this page.  


Citations:
==References==
<references/>


The Opioid-Free ED: Coming Soon to a Hospital Near You. Medscape. Feb 28, 2015.
[[Category:Pharmacology]]
[[Category:Palliative Medicine]]

Latest revision as of 17:59, 29 November 2020

Background

  • The shift in pain management from a symptomatic approach to a mechanistic approach has allowed providers to address pain in a more targeted and efficient manner
  • By recognizing the pain receptors that are the culprit behind a patient’s symptoms, a higher level of care can be administered

Pharmacologic Options

Below are a series of recommendations outlined by Dr. Sergey Motov and Dr. David Lyness. [1]

Abdominal Pain (Non Traumatic)

Abdominal Pain (Traumatic)

Back Pain (Nonradicular)

Burns

  • IV Ketamine 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour
  • IV Lidocaine 1.5 mg/kg of 2% over 10-15 minutes, + continuous infusion at 1.5-2.5 mg/kg/hour
  • IV Dexmedetomidine 02.-0.7 mcg/kg/hour drip
  • IV Clonidine 0.3-2 mcg/kg/hour drip

Headache

  • IV Metoclopramide 10 mg (slow drip 10-15 minutes) or IV Prochlorperazine 10 mg (slow infusion)
  • With IV Diphenhydramine 25-50 mg or IV Chlorpromazine 12.5 mg (slow infusion in 500 ml over 30 min - 1 hour)
  • SQ Sumatriptan 6 mg (within 1 hour of onset, 12 mg 1 hour later)
  • IV Ketorolac 10-15 mg or IV Diclofenac 75 mg or IV Metimazole 1 g
  • US Guided nerve block, Paracervical trigger point injections with 2% Lidocaine or 0.5% Bupivacaine
  • IV Haloperidol 2.5 mg, IV Droperidol 2-5 mg (slow infusion over 10 min)
  • IV Propofol (intractable migraine) 10 mg IVP q5 minutes
  • Refractory cases - Ketamine 0.2-0.3 mg/kg short infusion

MSK

  • US guided nerve block
  • IV Ketorolac 10-15 mg or IV Diclofenac 75 mg or IV Metimazole 1 g
  • IV Acetaminophen 1g over 15 minutes
  • IV Ketamine 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour

Neuropathic Pain

  • IV Ketamine 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour
  • IV Lidocaine 1.5 mg/kg of 2% over 10-15 minutes, + continuous infusion at 1.5-2.5 mg/kg/hour
  • IV Dexmedetomidine 02.-0.3 mcg/kg/hour IV infusion
  • Gabapentin (not included in Motov/Lyness regimen)
    • Day 1: 300mg PO qDay
    • Day 2: 300mg PO q12hr
    • Day 3: 300mg PO q8hr

Renal Colic

  • IV Ketorolac 10-15 mg or IV Diclofenac 75 mg or IV Metimazole 1 g
  • IV Acetaminophen 1g over 15 minutes
  • IV Lidocaine 1.5 mg/kg of 2% over 10-15 minutes
  • IN Desmopressin 40 mcg once as adjunct to NSAID’s
  • IV Ketamine 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour

Sickle Cell Crisis

Benefits

  • The cycle of opioid abuse and addiction often arises with the first time administration of opioids in the ED for a variety of medical complaints. Limiting this exposure is one of the ways providers can help combat this epidemic
  • A better understanding of underlying pain mechanisms will also likely result in overall improvement in pain management and satisfaction

Feasibility

  • A recent study being done at Maimonides hospital designed an 8 hour opioid free ED shift that resulted in over 80% pain satisfaction scores at 30 and 60 minutes and no opioids used during the shift with just one opioid prescription written[2]

Weaknesses:

  • During above study, a challenge was managing staff that had little experience in using medications for off label uses.
  • Certain subsets of patients will have various contraindications that will need to be considered such as patients with cardiovascular disease and NSAIDs. Those contraindications will not be reviewed on this page.

References

  1. ↑ *Lyness, D., & Motov, S. (2016, July 7). CERTA Opioid Alternatives and Analgesics. Retrieved July 25, 2016, from http://www.propofology.com/infographs/certa-opioid-alternatives-as-analgesics
  2. ↑ The Opioid-Free ED: Coming Soon to a Hospital Near You. Medscape. Feb 28, 2015.
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