Introduction
Working with patients in a prehospital setting has specific peculiarities impacting care delivery and outcomes. This environment can be described as a location where emergency medical care is administered to a patient before his/her arrival at the hospital. The inadequate assessment of patients’ states and treatment of acute conditions, including pain, can lead to numerous complications (1). However, statistics show that around 43% of adults suffering from pain in a prehospital setting remain undertreated because of various reasons (1). Under these conditions, the analysis of pain management practices acquires the top priority as one of the essential aspects to improve the outcomes associated with the prehospital setting. Moreover, regarding the concerns linked to the opioid epidemic, there is a tendency toward using non-opioid analgesics to treat moderate and severe pain. Thus, the proposed literature review focuses on analyzing opioid and non-opioid analgesics’ use in the prehospital setting, its peculiarities, and major aspects that should be considered when preferring one or another approach.
Pain Management in Prehospital Setting
The existing body of research admits the critical importance of pain management in the prehospital setting. For instance, a significant number of patients managed by emergency medical services (EMS) experience different levels of pain, from moderate to severe ones (2). The statistics show that 14% of clients reported mild pain, and 20% had moderate to severe pain (2). Under these conditions, pain management is a core component of prehospital care as it impacts the outcomes and the levels of client satisfaction (2). It also means that the choice of the method to alleviate pain and help clients acquires the top priority. Administration of required and effective analgesics is central for better outcomes and reduced number of adverse effects. However, nowadays, there is a specific issue linked to the choice of options by healthcare specialists. Traditionally, opioids such as morphine were considered the first choice for prehospital pain management, especially for acute pain (2). However, with the rise in the number of concerns because of the opioid epidemic, the massive use of opioids was reconsidered.
For this reason, nowadays, there is increased attention to using non-opioid analgesics as the method to manage pain in a prehospital setting. Moreover, by using this type of drugs, it is possible to address the problem of drug-seeking behaviors among clients and ensure there will be no substance abuse (2). Furthermore, researchers admit that the emergence of new and more effective non-opioid pain relievers contributes to the reconsideration of the approaches used to treat pain previously (3). As a result, the existing research literature evidences the EMS clinicians’ increased interest in using non-opioid analgesics in the prehospital setting (3). It contributes to the emergence of a debatable question of whether opioids can be replaced by their alternatives completely, especially in cases when the pain is severe. At the moment, there are numerous opinions linked to the effectiveness of drugs, side effects, and possible applications.
Opioids
As stated previously, historically, opioids were the primary choice to manage pain in a prehospital setting. It can be explained by several factors, such as the power of traditional beliefs, the lack of alternatives, and the need to improve patients’ states (2). Thus, the existing evidence about opioid administration to address acute pain in the prehospital setting is low (3). However, intravenous administration of fast-acting opioids or morphine effectively addresses severe pain and reduces its levels (3). Although there is a lack of understanding regarding the routes for opioid administration and prehospital pain management for risk groups, the method remains effective (3). Opioids help in most cases because of the mechanism of their functioning; however, there are concerns associated with the development of dependence or adverse effects (4). However, recent research shows that morphine can be used without severe complications at standard doses for prolonged periods (4). Moreover, its abuse can be prevented by the strict control of all procedures lined to administering and preparing the drug (4). In such a way, opioids remain one of the potent and effective ways to help patients in prehospital settings by managing their pain.
Non-Opioids
At the same time, the idea of using non-opioids for treating pain in prehospital settings is becoming more popular nowadays. Thus, the research study by Swift shows that using paracetamol, oxycodone, or codeine might effectively alleviate pain in specific groups of patients (5). The results show that non-opioid analgesia can also be used to manage moderate and severe pain linked to various conditions (5). Most patients prescribed this type of drug reported a reduction in pain similar to those who used opioids for the same purposes (5). It means the research does not show a statistically significant difference between using these approaches to manage pain in patients (5). This similarity in pain relief levels is a crucial factor showing the increasing number of opportunities for using non-opioid approaches to treating patients in prehospital settings. The idea that drugs such as morphine are more effective in addressing acute pain compared to paracetamol is challenged by the growing effectiveness of new methods (5). It means that most cases can be managed by selecting an alternative approach, and the choice of the pain alleviation method depends on the EMS clinicians and the guidelines provided to them.
Comparison
The growing number of concerns regarding the use of opioids and the increased popularity of non-opioid treatments introduces the need to compare the effects of various approaches. Previously, drugs such as morphine or synthetic opioids were considered the primary option for addressing patients in severe pain (1). However, the desire to reduce the dependence on opioids in the future and address the problem of drug abuse and drug-seeking behaviors impacts the broader implementation of other approaches. Thus, the existing body of literature offers several studies aimed at evaluating the effects of discussed methods. For instance, a comparison of opioid and non-opioid medication regarding their ability to enhance pain-related function provides essential information about the problem (6). The randomized control trial among 240 patients with a duration of 12 months does not show significantly better results peculiar to one or another method (6). It means that in a modern setting, treatment with opioids is not superior to non-opioid medicines (6). For this reason, the choice of the pain management model depends on the peculiarity of a specific situation, desired outcomes, and patients treated in the prehospital setting.
Opioid Pandemics and New Protocols for Paramedics
Speaking about the use of opioid and non-opioid methods of pain management and their choice, it is vital to consider concerns about the opioid pandemic. It refers to the significant increase in the distribution of opioids in the 1990s in the USA (5). Currently, it is considered one of the significant health concerns impacting the nation’s health (5). The research shows that in many cases, long-term opioid use starts with using them in prehospital management as the approach to mitigate pain (5). However, further diagnosing and prescribing opioids increases the risks of dependence and adverse outcomes (5). Under these conditions, the new guidelines for working with patients recommend the careful prescription of drugs to alleviate pain and replace them with medicines with a reduced chance of addiction development (7). It might impact the choice of approach to treating clients in prehospital settings.
Moreover, the fears associated with the opioid epidemic led to the introduction of new practice standards. Today, the initiation of opiates in healthcare settings is one of the disputable concerns because of the high risk of future misuse (7). For this reason, the fundamental role of opioid medications in prehospital pain management is being reconsidered (7). The existing literature shows that several states have already introduced non-opiate alternatives to meet the major needs of prehospital care (7). The introduction of new protocols helped to reduce opiate use from 100% to 90,6% (7). Moreover, 85% of paramedics planned to continue using non-opiates because of their effectiveness and ability to meet their basic needs (7). Although most patients were more likely to receive traditional painkillers, paramedics were more enthusiastic about the new options (7). At the same time, most fears about using non-opioid analgesics were associated with their ability to treat pain, onset time, and adverse effects (7). It means these factors might be central in selecting the treatment approach in the prehospital setting.
Adverse Effects
Finally, the choice of opioid or non-opioid analgesics can be linked to the adverse effects and complications caused by them. Thus, recent studies show that analgesic tolerance is one of the major complications in patients receiving opiates to treat pain (8). Addition and physical dependence might also be associated with prolonged morphine use (8). Patients also report constipation, nausea, vomiting, and respiratory depression (8). As for non-opioid analgesics, the risk of additional development is significantly lower (9). Moreover, this method is characterized by the reduced risk of respiratory issues, gastrointestinal problems, and analgesic tolerance (9). It means that opioids are potentially more dangerous medicines because of the high risk of adverse effects. However, in most cases, they are observed in prolonged use, meaning that the choice of the approach remains disputable for prehospital care.
Conclusion
Altogether, the existing literature outlines the tendency towards the broader use of non-opioid analgesics in prehospital settings. Numerous concerns associated with the opioid epidemic, the high risk of drug misuse, and the development of dependence are promoting the change in practice and increased topicality of new approaches to pain management. At the same time, opioids remain the most frequently used medicines for treating pain in the discussed settings. The research proves that non-opioids might have the same effectiveness in managing moderate and severe pain. Clinicians are enthusiastic about the use of non-opioids to help patients, while clients might have concerns about effectiveness, onset time, and possible adverse effects of alternative painkillers. Nevertheless, additional research is required to select the advantageous method as there is a lack of research data linked to the problem.
References
- Ferri P, Gambaretto C, Alberti S, Parogni P, Rovesti S, Di Lorenzo R, et al. Pain management in a prehospital emergency setting: a retrospective observational study. J Pain Res [Internet]. 2022;15:3433-3445.
- Lindbeck, G, Shah, M, Braithwaite, S, Powell, J, Panchal, A, Browne, L, et al. Evidence-based guidelines for prehospital pain management: recommendations. Prehospital Emergency Care [Internet]. 2022; 26: 1-11.
- Friesgaard KD, Vist GE, Hyldmo PK, Raatiniemi L, Kurola J, Larsen R, et al. Opioids for treatment of pre-hospital acute pain: a systematic review. Pain Ther [Internet]. 2022; 11(1):17-36.
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- Swift, A. Non-opioid analgesia is as effective as opioid management in acute pain and supports a change in prescribing practice to help address the ‘opioid epidemic’. Evidence-Based Nursing [Internet]. 2018;21:50.
- Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: The SPACE randomized clinical trial. JAMA [Internet]. 2018;319(9):872-882.
- O’Connor L, Dugas J, Brady J, Kamilaris A, Shiba SK, Kue RC, Broach JP. Paramedic pain management practice with introduction of a non-opiate treatment protocol. West J Emerg Med [Internet]. 2020;21(5):1234-1241.
- Paul AK, Smith CM, Rahmatullah M, Nissapatorn V, Wilairatana P, Spetea M, et al. Opioid analgesia and opioid-induced adverse effects: a review. Pharmaceuticals [Internet]. 2021;14(11):1091.
- Carter JA, Black LK, Sharma D, Bhagnani T, Jahr, J. Efficacy of non-opioid analgesics to control postoperative pain: a network meta-analysis. BMC Anesthesiol [Internet] 2020; 20: 272.