When Choosing the Right Analgesic Can Be a Pain

 

💊 The Pain Control Debate: Balancing Relief, Risk, and Reality in the ED

It starts the same way almost every shift.

You pull up the next chart and see it:
“Chief complaint: 10/10 pain.”

It could be a kidney stone, a dislocated shoulder, a sickle cell crisis, or back pain that’s been “the worst ever” since this morning. You sigh—because you already know what’s coming next. A decision that seems simple, but never is: How am I going to treat this pain?

Over the last few years, pain control in the ED has become one of our most heated, complex, and morally loadeddebates. Should we reach for opioids like we used to? Should we lean into ketamine, lidocaine, nerve blocks, or multimodal cocktails? And how do we navigate the tightrope between undertreating pain and fueling the opioid epidemic?

Let’s dig into the latest evidence — and the human realities behind it.

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🧪 Opioids Work — But at What Cost?

There’s no denying that opioids provide fast, effective pain relief. That’s why they’ve been a cornerstone of emergency care for decades. But the data has been shifting.

A 2023 meta-analysis comparing opioids to NSAIDs for acute musculoskeletal pain showed no clear superiority of opioids — and they were associated with more side effects like nausea, dizziness, and sedation (Daoust et al., 2023). In fact, codeine barely outperformed acetaminophen in some trials.

And for common complaints like low back pain, giving opioids may actually lengthen ED stays by up to an hour. One study showed opioid use increased LOS by 52 minutes compared to non-opioid management (Wasserman et al., 2022).

That’s a long time when the waiting room’s full, you're short on beds, and your charge nurse is giving you “that look.”

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💡 So What Are We Reaching for Instead?

In our department, we’ve slowly shifted toward multimodal pain management — not because we’re anti-opioid, but because we’re learning when other tools work just as well (or better).

Here’s what we’re using more often:

• NSAIDs + Acetaminophen: This combo works incredibly well for most mild-to-moderate pain, and many studies show it’s just as effective as opioids — with fewer risks.

• Ketamine (sub-dissociative doses): If you haven’t used low-dose ketamine for pain yet, it’s worth trying. A 2020 Cochrane review found it consistently reduces pain while preserving respiratory drive and mental status. It can be game-changing for trauma, long bone fractures, or when you’re trying to avoid opioids altogether.

  💉 Typical SDK dosing:

  • IV push: 0.1–0.3 mg/kg over 10–15 minutes

  • Infusion: 0.1–0.3 mg/kg loading dose, followed by 0.1–0.25 mg/kg/hr

  • Repeat dosing every 30–60 minutes as needed

• Regional anesthesia & nerve blocks: I recently saw a hip fracture patient breathe a literal sigh of relief after an ultrasound-guided femoral nerve block — no morphine needed.

• IV lidocaine: Great in select patients (renal colic, neuropathic pain), though use varies by institution and comfort level.

Our department started using an ALTO protocol (Alternatives to Opioids), and in less than a year, we dropped our IV opioid use by 20% — with no dip in patient satisfaction scores. In fact, a few people actually thanked us for not giving them narcotics.

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🎯 But Let’s Be Real: Sometimes, Patients Just Need Opioids

There’s still a place for opioids in the ED. Always has been. Always will be.

Some patients — especially those in sickle cell crisis, severe trauma, or palliative care — absolutely require them. And when they do, we shouldn't delay or shame that care.

The key is thoughtful prescribing:

• Short-acting meds

• Short courses (2–3 days)

• Clear follow-up

• Informed consent about risks and expectations

Sometimes, I just tell the patient directly:
"I want to help your pain in the safest way possible. We can start with non-opioids and see how you respond. But if that’s not enough, I won’t let you suffer."

That kind of honest, transparent conversation goes a long way.

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🧠 Pain Is Subjective. Compassion Shouldn't Be.

One of the hardest lessons I’ve had to learn is that pain is real, even when I can’t measure it. Even when vitals are normal. Even when the patient doesn’t “look” uncomfortable. And especially when unconscious bias starts to sneak in.

We’ve all seen the data — how patients of different ethnicities, genders, and age are less likely to receive adequate pain control for the same injuries. Protocols can help, but they can’t replace self-awareness, empathy, and accountability.

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🚨 The Bottom Line

Emergency medicine is evolving. Our approach to pain has to evolve with it.

Yes, opioids have a place. But they're not our only option — and often, they're not our best first step. Multimodal pain management isn’t just about reducing opioid use — it’s about expanding our toolkit, improving safety, and treating pain better.

So next time you're faced with a pain control decision — and you will be, probably within the next 15 minutes — just take a second to ask:

“What’s the safest, fastest, and most compassionate way I can treat this pain… for this patient?”

That mindset will serve you — and your patients — far better than any single drug ever could.

#bloggingfromthebay

— CrashCart Kelly

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📚 References

• Daoust R et al. (2023). Opioids vs. Non-Opioids for Musculoskeletal Pain. Annals of Emergency Medicine.

• Wasserman R et al. (2022). Opioid Use and ED Length of Stay in Back Pain. JAMA Network Open.

• American Academy of Emergency Medicine (2021). White Paper on Pain Management in the ED.

• Motov S et al. (2020). Alternatives to Opioids (ALTO) Protocols: Results and Implementation. Academic Emergency Medicine.

• Vreeland M et al. (2019). ALTO in Practice: Opioid Reduction without Sacrificing Satisfaction. Western Journal of EM.