Opioid Miniseries Part III: Alternative to Opioids - The Emergency Medical Minute

PRACTICE RECOMMENDATIONS

1. All emergency departments should implement ALTO programs and provide opioid-free pain treatment pathways for

the following conditions:

a. Acute on chronic opioid-tolerant radicular lower back pain

b. Opioid-naive musculoskeletal pain

c. Migraine or recurrent primary headache

d. Extremity fracture or joint dislocation

e. Gastroparesis-associated or chronic functional abdominal pain

f. Renal colic

2. Emergency departments should integrate ALTO into their computerized physician order entry systems to facilitate a seamless adoption by clinicians.

3. Low-dose, subdissociative ketamine (0.1-0.3 mg/kg) is an effective analgesic that can be opioid-sparing for many acute pain syndromes. Institutional guidelines and policies should be in place to enable clinicians and nurses who administer this agent for pain.

4. For musculoskeletal pain, consider a multimodal treatment approach using acetaminophen, NSAIDs, steroids, topical medications, trigger-point injections, and (for severe pain) ketamine.

5. For headache and migraine, consider a multimodal treatment approach that includes the administration of antiemetic agents, NSAIDs, steroids, valproic acid, magnesium, and triptans. Strongly consider cervical trigger-point injection.

6. For pain with a neuropathic component, consider gabapentin.

7. For pain with a tension component, consider a muscle relaxant.

8. For pain caused by renal colic, consider an NSAID, lidocaine infusion, and desmopressin nasal spray.

9. For chronic abdominal pain, consider low doses of haloperidol, diphenhydramine, and lidocaine infusion.

10. For extremity fracture or joint dislocation, consider the immediate use of nitrous oxide and low-dose ketamine while setting up for ultrasound-guided regional anesthesia.

11. For arthritic or tendinitis pain, consider an intra-articular steroid/anesthetic injection.

POLICY RECOMMENDATIONS

1. Hospitals should update institutional guidelines and put policies in place that enable clinicians to order and nurses to administer dose-dependent ketamine and IV lidocaine in non-ICU areas.

2. Emergency departments are encouraged to assemble an interdisciplinary pain management team that includes clinicians, nurses, pharmacists, physical therapists, social workers, and case managers.

3. Reimbursement should be available for any service directly correlated to pain management, the reduction of opioid use, and treatment of drug-addicted patients.

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