EMS Opiates and Chronic Pain – 2

I wrote recently about my new found concern about giving opiates to patients with chronic pain.

Opiates for Chronic Pain

Subsequently as a member of our regional medical advisory committee, I submitted the following draft proposal:

Paramedic Chronic Pain Management Guidelines (Draft)

Providing opiates to certain patients with chronic pain conditions may not always be in the best interests of the patient and has the potential to cause them harm.

Paramedics may consider deferring opiate pain management for patients with chronic pain if they have any of the following high risk flags:

Poly-Hospital, frequent EMS calls for same condition, allergies to analgesics and other relevant non-opioids, transfer request to distant hospital, history of substance abuse.

Paramedics should still document patient’s pain and institute other pain management techniques such as positioning, distraction therapy and guided imagery.

Paramedics should continue to treat acute pain and cancer pain aggressively. They also have the option to treat breakthrough chronic pain, after considering the possible risk to the patient.

I added the following note to the committee

Currently we provide pain relief to any patient with acute or chronic pain of 4 or greater. I have advocated for this in the past believing there was no harm to the patient. If, however, as some in the medical community believe, there is harm in providing opiates to certain patients in chronic pain, I thought we should address the issue. I have attached slides from a presentation on the issue by Dr. Rueben Strayer, along with his risk stratification strategies that I have adopted for EMS. While his lecture is directed to the ED, it has some ramifications for EMS.

I am no great rush to approve this document. I submit it as a unit of discussion, and would look for the guidance of the doctors on whether or not such a guideline is of merit.


I had second thoughts almost immediately after submitting it. My second thoughts were that because our pain management is so inadequate currently (multiple QA cases of patients with severe pain not getting medicated and general overall low rate of pain management), my proposal might give some paramedics an excuse not to medicate deserving patients.

When we talked over the proposal at the committee, a few others seconded that concern. I did not aggressively push it, and was satisfied that we agreed to look at how other systems addressed the issue of chronic pain.


Since I raised my concern, I have encountered a number of chronic pain patients in severe pain, and when dealing with these people face to face, I have found it difficult to not offer pain medicine. I give it, their pain is relived — at least temporarily, and they thank me for treating them kindly.

I hope I am doing right by them.


  • Ian says:

    Kudos for doing so! Having used Dr Strayer’s slides myself, I think you could have gone even farther with the red flags into some yellow flags.

    There are plenty of lazy medics, or those that just don’t know any better. I personally open my kit almost once a shift, sometimes more, but there are patients who should not get opiates. As long as as have the ability to withhold and as long as we articulate why, we are doing better. The evidence for chronic pain and PTSD from that pain is flimsy at best.

    We need to put pain management in the category it belongs in – symptom relief/patient comfort. It is not treatment of a life threatening condition.

  • EMS Artifact says:

    I recently had a discussion with an EM physician whom I have known for several years and whose opinion I highly respect.
    Her sense is that medicine in general over treats chronic pain and under treats acute pain.
    I think she’s right and while EMS has a significant role in treating acute pain (or should), the role of EMS in the treatment of chronic pain is far less clear.
    This is all the more important in light of the opiate overdose epidemic in some parts of the country.

    Just because we can do something, doesn’t necessarily mean that we should do it.

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