Should paramedics give opiates to patients with chronic pain?
I want the answer to this question.
Now, until recently I have not questioned this practice. Today, I still medicate (well, most*) patients with chronic pain of 4 or more, who do not have contraindications, and who say yes when I ask them if they want pain medicine. I am following our regional pain guidelines, which I helped write. Underlying the guidelines in the premise that pain is what the patient says it is, and human suffering should be relieved.
Today at one of the hospital EMS rooms, I saw a flyer for a CME being offered on February 10 at a local ambulance service (Windsor) about pain management that included a mention of when it was appropriate and when it is not appropriate to give a a patient opiate pain meds. My question! It sounded like an absolutely first rate CME, which unfortunately I can't make because I will likely still be at work on the ambulance when the CME kicks off. The flyer mentioned a virtual guest speaker, Dr. Ruben Strayer. I googled the guest speaker and found this fascinating lecture that questions giving opiates for chronic pain. Now while his lecture does not get down to the paramedic level, it does touch upon the ED MD.
Pain, Compassion, Addiction, Malingering: How To Use Opioids (and how to not use opioids)
Having only listened to it once, it boils down to this.
Big pharma funded a huge effort to convince doctors that opiates are harmless, so people were overprescribed opiates, and this created a generation of addicts that has wreaked havoc on our nation as the opiate epidemic is killing more people today than motor vehicle accidents and destroying families and millions of lives. I wrote about this recently in Pain Myth.
And key to my question, Strayer says giving opiates for chronic pain may in fact be harmful for patients, and while providing temporary relief, may cause hyperanalgesia (where opiates actually make patients more sensitive to pain), and it may further their dependence and make them sicker. There may be better alternatives, he suggests. He breaks down the risk strategies that an ED MD should go through before giving opiates. Perhaps such a model could be developed someday to help paramedics decide who to administer opiates and who to defer treatment to the ED.
Here is an except from the web page about the talk:
For patients at high risk to be harmed by opioids, including patients with chronic pain and patients with flags for opioid misuse, avoid using opioids in the ED and outpatient settings, utilize non-opioids to manage symptoms, and, when misuse is suspected, nudge the patient to addiction treatment.
If opiods may be harmful in the ED setting, then maybe they are harmful in the prehospital setting. If they are, I don't want to give them.
I am not ready to change yet, and before I change, if I become convinced of a better way, I will try to change our paramedic treatment guidelines at the same time. I want to hear what other doctors who I respect think of Strayer's ideas and the general issue, and I, of course, want to read more about this topic.
Two points to make clear. Strayer is not talking about acute pain or about cancer pain. Both of those categories are clearly appropriate to treat with opiates.
As a footnote, in his talk, he mentions the possible benefits of ketamine for chronic pain, and he also says marijuana may be better and less harmful for someone with chronic pain than opiates. I have been in EMS many years, but doubt I will be around long enough to light a bong pipe for a patient in the back of my ambulance. Strayer, of course, is not advocating this either. But a prescription for medical marijuana may in the future replace percocets as the take home prescription of choice.
Bottom line, it is a provocative talk, and as an almost militant pain management advocate, it caught my attention.
*If I believe a patient is outright lying to me, I may withhold medication. The same with if the patient has been identified to me as a patient who an ED does not want getting opiods, then I will withhold. In general, I have always erred on the side of the patient and given the opiate.
