Non-Opioid Pain Management

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.

Massachusetts Pain Management Protocol

Emergency Non-Opioid Pain Treatment Options Update

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.

Efficacy of Intravenous Paracetamol Versus Intravenous Morphine in Acute Limb Trauma.

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.

When IV Acetaminophen Prices Suddenly Skyrocketed

IV APAP Works, So Why Don’t More EPs Use It?

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.


  • Greg Friese says:

    Any reason for the delay until 1/1/2018? Why not making it effective immediately.

    This is a great point

    “cost of IV acetaminophen might be mitigated by the savings of not having to take an ambulance off-line for controlled substances exchanges”

    • J.Spencer says:

      Massachusetts has committed to an annual update with their protocols with the exception of emergent changes. This was not seen as an emergent change and therefore will be rolled out with any other changes during the annual update. It just makes the educational roll-outs and phase in of new required items easier for their services.

  • CR says:

    I wonder when we will start to see more systems use ketamine for non-opiate pain management

    0.15-0.30 mg/kg IV over 10 minutes.

    We are starting to use this in some areas of Canada at the ALS/CCT level and it is highly effective.

  • Renee Atherton. says:

    This protocol change IS an emergency change and as soon as a service obtains the medications through their affiliate pharmacy and successfully completes the training they can adminster the non-opiod medication options. The 1/1/2018 date is a “ no later than” date ….. if anyone has questions on this please contact me directly at

  • BH says:

    Rhode Island authorized PO Ibuprofen, acetaminophen, and ASA, as well as NO and Toradol for non-opioid management during a major protocol update back in March. All but the Toradol are BLS.

  • JK says:

    Here in New Zealand we have had paracetamol and ibuprofen for a number of years, added to this we have the opiates tramadol, morphine and fentanyl and the option of low dose midazolam and ketamine.

  • Timothy Clark says:

    And we will have Ketamine in January. Its great to hear what other States are implementing!

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