Acute Pain Control in the Emergency Setting: Non-Narcotic Alternatives

“Ma’am I understand your situation. I know it hurts you every day. I know it keeps you from doing the things you love to do, and I know that you’re getting depressed from the constant agony and the inability, but my hands are tied because your doctor has placed a message in your file that you’re not to have any more refills of Oxycontin, unless he personally authorizes it.”  I know that this scenario is probably familiar to many of you.  On the prescribing side, I have to tell them that it would be medically irresponsible for me to keep writing the prescriptions and perpetuating a bad situation.

Everyone has varying thresholds and tolerances for given levels of painful stimuli.  This is in part due to each individual’s unique physiologic makeup, where one person can simply withstand a higher level of pain either because they can’t feel it as badly as someone else, or they can ignore it whereas someone else would be in tears.  Another factor is the learned response of pain and its effect on the individual.  This learned response can vary as a result of differing parental feedback when their children takes their first few falls, as well as cultural, and social influences. Working in emergency medicine, I’m surrounded by more people in chronic pain than most in their daily jobs.   I’m just as guilty as the next guy when I greet certain patients with a smile, while in my mind I’m thinking, “Geez, western medicine has really created a generation of wimpy people, and I wish I could just tell them to go home and suck it up.” Don’t get me wrong, I don’t like to see anybody in real pain, and if they are truly in agony, they deserve pain relief.  No one should have to truly suffer.  But as we all know, many of the people that come in for their Vicodin refills aren’t really in enough pain to warrant chronic narcotic use. With that in mind, let’s look at a different approach to pain control.

Pain is an idea. Yes, pain is simply a processed nerve impulse that is recognized as an uncomfortable feeling.  When you think about it, a nerve impulse is really just an electrical signal traveling up a wire, nothing more.  It doesn’t mean anything while it’s traveling from the receptor up the afferent nerve, toward your brain. It’s not until the brain sorts it out and recognizes it, and sends it to your cerebral cortex, that you even realize something hurts! Are you with me? So, if we believe that pain is merely an idea, how can we change the patient’s mind?  How can we change the patient’s perception of that idea?

Some people in chronic pain have been treated with anti-depressants such as Neurontin, but often this medication, is slow to work, and has limited effectiveness.  Furthermore, it’s not appropriate for acute pain or a higher level of pain such a migraine headache?  In the good old days, we would simply give them a shot of Demerol or morphine. The patient was happy, (if not asleep), and you wouldn’t get into an argument with them because you didn’t give them their rightful shot. These days, however, with increased medical legal responsibility and lawsuits, ER abuse, and drug seeking malingerers, there is a rapid increase in policies being enforced in hospital emergency departments to use an alternative class of medication for the treatment of high-level pain.  This is especially true if the initial dose of the narcotic medication seems to have little or no affect.

I love those old movies where a psychotic patient would be subdued by psych techs in clean white outfits, and you would hear the doctors say, “Nurse, give him 50 mg of Thorazine STAT!”  The nurse would give him the shot, and the crazed patient would immediately stop fighting, and crump to the ground.   After which they would strap him into at straight jacket.  These days, as you may know, the phenothiazine class of medications have many more applications, then a simple antipsychotic. Drugs like Thorazine, Haldol, Compazine, Phenergan, and the like, are commonly administered intravenously and seem to work magically for poorly controlled pain.

As a result, a patient with a blinding headache will miraculously remove his or her sunglasses, get up from the gurney pain free, and asked the nurse if they can leave.  Back pain sufferers, who minutes ago were posturing and writhing, literally, get out of bed, put on their pants and are ready to dance a jig!  Now, this may not be the final solution for the patient’s suffering, but it can interrupt the cycle of pain long enough for the patient to get a good nights’ sleep. Change their perception of the idea of pain, change their pain altogether.  Sometimes, that’s all it takes.