Pain control - Recent controversies and research

Second post, and I wanted to go over recent issues in one of my favorite topics, prehospital analgesia. I found a couple discussions in EMS forums that piqued my interest. If you don't want to stick around for the conclusion, I'll give it to you here now; you can feel safe in using the SHCGB protocols to treat pain, and using them aggressively.

You can give morphine to patients with abdominal pain, you can give it to pregnant patients - no worries. 

You can also feel extremely comfortable with the protocol dosing. Giving 2-5mg IV of morphine, to a total of 0.1 mg/kg, is a very conservative dosing strategy.

Opiods in pregnancy
One discussion I found over at JEMS Connect involved pain management for a pregnant female who had sustained an isolated femur fracture in an MVC. A number of folks, as well as the OP, expressed some concern about the effect of opiods on the fetus, and felt accordingly hesitant about giving morphine or other meds in that situation. One of the quotations stood out to me - "I am normally a huge advocate of pain management in EMS but the risks (harming the fetus) don't seem to outweigh the benefits (not being in pain) when all things are considered."

I'm sympathetic - after all, primum non nocere! You would think that there would be more written on the topic, but Rosen's, the 18 pound bible of EM, says only that "The short-term use of opiates appears to be safe in pregnancy," but doesn't give us any evidence to support that.

Opiods in abdominal pain
Another forum posting, this time over at CTFIRE-EMS, was a discussion trying to elicit people's feelings about giving analgesia as a medic in general. One of the more interesting points was about giving analgesia to a patient with abdominal pain, with one poster believing that "most if not all surgeons would prefer to examine the abdomen before pain meds are given." Other posters weighed in with different opinions (Clashing opinions in a paramedic forum? Unheard of!),  and the observation that protocols in CT are evolving.

Our protocols
And what do the SHCGB protocols recommend? The language is clear:

"Patients in severe pain (7-10/10), in whom a narcotic analgesic will have a beneficial effect on outcome should be considered as candidates for pain management."

No exceptions for abdominal pain, pregnancy, young or old age - go for it!

In the second part (coming up!) I'll go over some recent research about prehospital narcotics, and I'll review some of the other protocols out there. I think it'll really drive home why you can feel safe using our protocol aggressively.