Paramedic Pain Management Practice with Introduction of a Non-opiate Treatment Protocol

Abstract

Introduction: There is concern about the initiation of opiates in healthcare settings due to the risk of future misuse. Although opiate medications have historically been at the core of prehospital pain management, several states are introducing non-opiate alternatives to prehospital care. Prior studies suggest that non-opiate analgesics are non-inferior to opiates for many acute complaints, yet there is little literature describing practice patterns of pain management in prehospital care. Our goal was to describe the practice patterns and attitudes of paramedics toward pain management after the introduction of non-opiates to a statewide protocol. Methods: This study was two-armed. The first arm employed a pre/post retrospective chart review model examining medication administrations reported to the Massachusetts Ambulance Trip Information System between January 1, 2017-December 31, 2018. We abstracted instances of opiate and non-opiate utilizations along with patients' clinical course. The second arm consisted of a survey administered to paramedics one year after implementation of non-opiates in the state protocol, which used binary questions and Likert scales to describe beliefs pertaining to prehospital analgesia. Results: Pain medications were administered in 1.6% of emergency medical services incidents in 2017 and 1.7% of incidents in 2018. The rate of opiate analgesic use was reduced by 9.4% in 2018 compared to 2017 (90.6% vs 100.0%). The absolute reduction in opiate use in 2018 was 3.6%. Women were less likely (odds ratio [OR] = 0.78, 95% confidence interval [CI], 0.69-0.89) and trauma patients were more likely to receive opiates (OR = 2.36, CI, 1.96-2.84). Mean transport times were longer in opiate administration incidents (36.97 vs 29.35 minutes, t = 17.34, p<0.0001). We surveyed 100 paramedics (mean age 41.98, 84% male). Compositely, 85% of paramedics planned to use nonopiates and 35% reported having done so. Participants planning to use non-opiates were younger and less experienced. Participants indicated that concern about adverse effects, efficacy, and time to effect impacted their practice patterns. Conclusion: The introduction of non-opiate pain medication to state protocols led to reduced opiate administration. Men and trauma patients were more likely to receive opiates. Paramedics reported enthusiasm for non-opiate medications. Beliefs about non-opioid analgesics pertaining to adverse effects, onset time, and efficacy may influence their utilization. [

Influence of patient sex on pain management practices in Paramedicine: A rapid review

“…Some studies have indicated that females are disproportionality treated less for their pain, even when the complaints of pain are similar to males. 37,38,[40][41][42][43][44] This may create an equity of care and patient safety problem in prehospital care, as female patients may go longer without adequate pain relief. This is important to note as some research shows that females experience more severe, longer lasting and recurrent pain.…”

“…All studies met the methodological quality rating threshold of 60% with four studies having a quality rating of 100%, 38,[40][41][42] seven having a quality rating of 75% 37,[43][44][45][46][47][48] and two having a quality rating of 62.5%. 39,49 All ROB scores are listed in Table 2.…”

“…The 13 included studies were conducted in ambulance services in multiple countries: USA (n = 5), [37][38][39][40][41] Australia (n = 3), [42][43][44] England (n = 1), 45 Italy (n = 1), 46 South Africa (n = 1), 47 Switzerland (n = 1) 48 and Sweden (n = 1). 49 All but one of the articles, 49 were conducted retrospectively, analysing data that had been routinely collected by an ambulance service as part of patient management.…”

“…38,[40][41][42][43] Lord et al 42 identified that there was no sex disparity in the administration of methoxyflurane and/or morphine as a whole, however when looking at morphine specifically, males were significantly being administered morphine at a higher rate. O'Connor et al 37 investigated non-opiate and opiate administration, with the results indicating that males had a higher rate of being administered an opiate whereas females had a higher rate of non-opiate administration. Supples et al 40 noted that whilst females were more likely to have their pain assessed and reported higher pain scores overall, males had statistically higher likelihoods of receiving analgesia.…”

Polish Experiences of Pain Treatment by Paramedics in relation to Good Practices of Pain Treatment: A Register-Based Study

“…The treatment of pain at the prehospital care level is a major concern in many healthcare systems all over the world [ 8 – 11 ], being one of the priority activities for paramedics [ 12 ]. The first large-scale analysis in Poland concerning application of pain assessment showed how often and in what situations paramedics use pain scales, what medications and whether multimodal analgesia they use and with what effect.…”