Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Pain Management – What is too much?

I was looking at some protocols from another area and saw that, although their protocols are basically more restrictive than my too restrictive protocols, the notes about management had some clear and sane advice on the management of narcosis – the oversedation from an opioid.

The notes included more than I clipped, including continuing the presumption that opioids will cause nausea and vomiting. N/V from opioids is almost always due to the rate of administration, not the dose, not the drug, not anything else. At least, that has been my experience.

There are far too many misguided rituals that surround the administration of this supposed Damoclean chemical. It was nice to see a segment of common sense mixed in

Respiratory depression should be treated with oxygen and ventilatory support if necessary.
• Attempt verbal and tactile stimulation to reverse respiratory depression prior to considering
naloxone (Narcan®).
• Administer the smallest possible reversal dose of naloxone to maintain adequate respirations.
Dilute 0.4 mg naloxone in 10cc 0.9% NS syringe and slowly titrate to effect.
The most important part was probably too simple to be written into the protocols.

If the patient is talking the patient is breathing.

This concept seems to be overly simplistic for some doctors, but where is it wrong?

What if the patient is not talking?

Well, if I gave them enough opioid to manage their pain to the point where they are too comfortable and just want to be let alone to nod off AND there is respiratory depression – they are going to stay awake and talk to me for the rest of their time with me. At the hospital they will be encouraged to continue talking while the management of a bunch of morphine is considered by the doctors and nurses. If fentanyl had been the drug used, then the problem should not have been a problem after transferring the patient at the ED. Fentanyl is metabolized quickly and that is why it is the most appropriate EMS pain management drug.

If they are just not interested in talking, are breathing well, and are indicating that my conversation is now their greatest pain, then they can rest; if respiratory depression develops, then they do not have the option of avoiding conversation. If they wish to yell at me to leave them alone, that keeps air moving, too.

If you think that I give enough opioid to prehospital patients to achieve this effect, I do not. I have assisted/observed plenty of procedural sedation in the ED. Not as a replacement for a nurse, just lending an extra hand to do grunt work. Not a lot of anti-nausea medication used in these procedural sedations, either. Just nice slow administration, reassessment, and repeat as necessary.

It is amazing how much you can learn from someone who knows what they are doing. I think medic schools would benefit tremendously from requiring medics to assist with procedural sedation, or in the burn unit, to develop an understanding of what happens with large doses of opioids. The lesson is not to use the same doses, but to see how to manage the patient if the dose is unintentionally too large.

We let numbers scare us to the point where we ignore the patient. This is bad.

Less-than-cheerful nurse: “You gave 26 mg of morphine to that 45 kg little old lady? Are you insane?”

RM: “Which part do you want me to answer first?”

Less-than-cheerful nurse with a sense of humor: “I guess that answers the second question. Why so much morphine?”

RM: “She has 2 Duragesic patches on; had severe pain; and, even with that much morphine, her pain level is still 4/10, increasing to 7/10 with movement. She felt the pain was tolerable when we moved her, we had already spent a lot of time on scene, and we did not want to switch protocols to compartment syndrome. :-)”

The nurse, although Less-than-cheerful, yet in possession of both a sense of humor and the ability to assess the patient and determine the appropriateness of the dose proceeded to do just that. The patient is awake, alert, oriented, and rates her pain as 4/10. Now the nurse is the Less-than-cheerful nurse with an anecdote to share with the rest of the staff. All of this required on line medical command (OLMC) orders, which were fortunately provided by an aggressive ED physician. With the OLMC roulette that we play, you never know how much appropriate care you may be able to provide to the patient.

Well, I didn’t get the patient to the point of being pain-free, but that is not my goal. A tolerable level of pain is all that should be hoped for with morphine. Fentanyl allows for more aggressive dosing due to its much more rapid metabolism. Metabolism is the medic’s friend.

As clarification for the non-medical people Duragesic is a brand name of fentanyl patch that gives fentanyl slowly over a long time; it is absorbed through the skin; even though the fentanyl that is given by EMS is metabolized (used up quickly in the body) quickly, the slow absorption through the patch of the same drug lasts a long time. Fentanyl can be given IV, IM, and by an atomizer spray in the nose, so that an IV is not always needed (little kids, poor veins, …).

Appropriate use of benzodiazepines is not much different from appropriate use of opioids.

Does anybody have any interesting pain management ideas, anecdotes, questions, … ?

I also wrote about this here:

Public Perception of Pain Management



  1. In the words of the immortal Keith Richards, “Too much is never enough!”I am more than a little disappointed that it took FOUR posts until you used a Greek Mythology reference.This is to say nothing of the shameful dearth of Latin on your blog!You do hit the syringe on the plunger with this post. It has been my experience that most docs are conservative when it comes to managing pain with opiates; clinging to the old adage that it is easier to add more medicine than take it away. This is a reasonable and responsible way to proceed.I have seen however, that sometimes there is great reluctance to increase dosages after a certain point. There is a certain mentality among some clinicians where anecdotal evidence and thinking that X mgs is WAY too much for Y patient persists. Sometimes this is not the best for our patients as you can imagine.As you know there are a myriad of factors that dictate “proper” dosing. These include body mass, metabolic state, hepatic / renal function, previous opiate experience, and type and severity of perceived pain. There is no such thing as one-size-fits-all dosing for pain.In my opinion the way to approach urgent pain management with opiates is to work to a clinical endpoint i.e. an “acceptable” level of pain as tolerated by the patient; not some arbitrary dosage maximum.(sorry for deleting the first comment..too many typos!)

  2. The fentanyl does not last for a long time. The surgeon does not get to the patient for a long time. Why can’t we use fentanyl for abdominal pain and other stuff that is not just a broken arm or leg?

  3. Inchoate makes an excellent point, and more briefly than I do.There is does not appear to be a good reason to avoid treating abdominal pain in EMS. When using fentanyl the few concerns about “interference with assessment” disappear.Conditions other than extremity fractures are significantly undertreated, too. Concerns about hypotension are much less significant with a drug that does not appear to lead to vasodilation caused by histamine release.Generally, the more rapidly a drug is metabolized the safer the drug is in the EMS setting.

  4. Vince,I pre-deleted my first response, so we’re even.OLMC requirements delenda est. At least to appease Vince’s lust for Latin and to quash AD’s nagging fear.