Opioid free regimens

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.

Abdominal Pain (non traumatic)

• IV Ketorolac 10-15 mg or IV Diclofenac 75 mg or IV Metimazole
• IV Acetaminophen 1g over 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

Abdominal Pain (traumatic):

• IV Acetaminophen 1g over 15 minutes
• IV Ketamine 0.3 mg/kg over 10 minutes, + IV drip at 0.15 mg/kg/hour

Back Pain (nonradicular):

• 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
• IV Acetaminophen 1g over 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

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

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 Vaso-Occlusive Crisis IN Ketamine 1 mg/kg (no more than 1 ml per nostril) 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

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 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.

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.

Citations:

The Opioid-Free ED: Coming Soon to a Hospital Near You. Medscape. Feb 28, 2015.