Newer options that have been promoted include tapendtatol and tramadol. The former has turned out to be a very poor analgesic that costs a lot of money, whereas the latter has not gained much favor in the emergency physician community. Neither is at risk for abuse, and tramadol does offer valid analgesia in many patients. It might be of value to provide it in the ED to see how helpful it is prior to writing a prescription for it.
The NSAID with the best analgesia/anti-inflammatory/safety profile still is ibuprofen. It is the recommended analgesic of choice for dental pain. For new onset or a flare of chronic sciatica or other neuropathic pain, short-acting opioids will rarely help the patient. A combination of a NSAID with a tricyclic (nortriptyline is less sedating) is probably best. It is important to note that the starting dose of the tricyclic should be 25 mg at bedtime, rapidly titrated over seven to 10 days to at least 75 mg and with follow-up with a primary care provider. Carbamazepine for tic douloureux should be started at 200 mg and titrated up 200 mg every three days to effect, again with follow-up within one week. Initiation of either a tricyclic or a gabapentanoid (gabapentin 300 mg, increasing by 300 mg every three days to effect, or pregabalin 25 mg a day with much slower ramp up due to side effects) for postherpetic neuralgia (PHN) is an excellent option. See Table 1 for more recommendations for treating neuropathic pain.
Many nonopioid options exist, but to use these medications optimally and safely, a much greater understanding of pain mechanisms is required. Opioids have their place but a much smaller one than what was seen in the nondiscriminate symptomatic approach era.
Dr. Ducharme is editor in chief of the Canadian Journal of Emergency Medicine and clinical professor of medicine at McMaster University in Hamilton, Ontario.
Brief Script of How to Say No to the Opioid-Seeking Patient
Here are two variations of a script I use routinely. It is always essential to get two points across to patients:
- You are willing to help them manage their pain.
- You know the rules of the game.
Using variants of the below, I can count on one hand the number of times in the past five years the situation degenerated to where the patient was swearing or yelling.