Stuck Between Narcotics and a Hard Place
This image is from a video I found on youtube that describes the relative potency of pain medications. The content creator sets hydrocodone (and oral morphine) as the basis for his comparison. For example, aspirin (“ASA”) has 1/360 the pain relieving efficacy of hydrocodone. Fentanyl has 50 to 100 times the pain relieving efficacy of hydrocodone.
In the emergency department, pain is obviously important to manage. It’s been important for me, as a new nurse, to learn how to properly assess pain and how to advocate for my patients’ pain management. The key question is: what is the appropriate pain management strategy for a particular patient?
At first glance, this question may seem straightforward. Match the pain medication to the patient’s level of pain and sustain pain relief for as long as possible.
Fentanyl is an important tool in our toolbox because it is fast-acting and very powerful pain relief — but it wears off quickly for many patients. Hydromorphone (also known as Dilaudid) and morphine are also strong pain relievers and last longer than fentanyl. All of these are opioid medications (sometimes also referred to as “narcotics”). Non-opioid pain medications are also important tools to consider.
However, putting what I’ve learned about pain relief to work in practice involves a lot more consideration than I previously anticipated.
For example, the complexity of the patient’s clinical picture can change the pain management strategy. I recently cared for a patient who had just been discharged from an ICU stay for pneumonia and had returned to the ED complaining of shortness of breath and pain in her back.
Incidentally, she also met our criteria for alcohol withdrawal, so we treated her with Valium in order to prevent withdrawal seizures. Our doctor was reluctant to give the patient opioid pain medication on top of the Valium due to the potential for these drugs to depress respiratory drive. The patient was very dissatisfied with this and opted to leave the hospital against medical advice.
Every shift I work, I see providers struggle to develop a successful pain management strategy for patients. Each and every patient is unique in terms of how they perceive pain, how they cope with pain, and how their clinical picture influences pain management strategies.
