The state of Massachusetts just passed an emergency protocol change requiring all paramedic ambulances to carry non opioid pain management alternatives, including Ibuprofen PO, Acetaminophen PO and Ketorolac IV or IM. Acetaminophen IV is optional. The changes are to take place January 1, 2018.
Here is the dosing regime:
Acetaminophen 1000 mg IV or PO
Ibuprofen 600 mg PO
Ketorolac 15 mg IV or 30 mg IM
Acetaminophen 15 mg/kg IV or PO to max 1000 mg.
Ibuprofen 10 mg/kg PO to max 600 mg.
Ketorolac 0.5 mg/kg IV or IM to max 15 mg.
The Massachusetts protocol includes the following note:
All pain medications have contraindications-do not administer medications in
such circumstances. These contraindications include but are not limited to:
Ketorolac and ibuprofen are contraindicated in head injury, chest pain, abdominal pain,
or in any patient with potential for bleeding, ulcer, or renal injury; likely to need surgery
Acetaminophen is contraindicated in patients with liver failure. Ketorolac and ibuprofen
are contraindicated in pregnancy.
Many states, including Massachusetts and Connecticut, have been passing laws allowing patients to fill out non-opioid directive forms. This will allow patients who want to avoid opioids a pain management alternative beyond ice and splinting. I have had many patients decline opioids, ranging from patients in recovery to patient to others fearful that “Fentanyl” will send them down the road to addiction and death. While those fears are largely unrealistic in the context of fentanyl being used for an acute painful injury, avoiding opioids if there is another alternative is probably not a bad idea.
I was not even aware that Acetaminophen could be given by the IV route or that it was considered as effective as morphine, but a recent randomized controlled study published in Trauma Monthly showed it was safe and efficacious and even outperformed morphine in the trial.
One drawback to IV Acetaminophen is its price — $36 for a one dose 1 gram vial, compared to $2.40 a dose for fentanyl or morphine. As it so often seems, the price of a suddenly popular drug seem to suddenly skyrocket.
Our Regional Medical Advisory Committee will be considering a similar protocol when we meet next week. In our area, the cost of IV acetaminophen might be mitigated by the savings of not having to take an ambulance off-line for controlled substances exchanges at a hospital pharmacy every time they use Fentanyl or Morphine.