Treating acute pain is a challenge we face during every urgent care shift. We’re all aware of the devastation that the opioid crisis has had on millions of people worldwide. And this epidemic - marked by addiction, overdose, and unintended consequences - has highlighted the need for alternative treatments to manage pain.
As clinicians, we regularly encounter patients wanting or expecting opioids to treat their pain. For years, opioids were the go-to option. We’ve since learned that even short-term opioid prescriptions can lead to tolerance, dependence, and addiction, making them a potentially risky choice for pain management.1 However, not all providers are comfortable or possess the knowledge to discuss safer and more effective alternatives to opioid medications.
By the time patients decide to come to urgent care, they’ve often tried over-the-counter medications such as acetaminophen and ibuprofen to manage their pain. We know these medications are highly effective when dosed appropriately. However, patients rarely know how to dose these medications correctly, which is possibly why many of them report them to be ineffective.
Statistics have shown that in head-to-head trials with combined acetaminophen and ibuprofen versus that combination in addition to opioids, the same pain reduction score was achieved.2 This is valuable information that we can share with our patients to help them understand that we’re all trying to accomplish the same goal and not trying to deny them treatment for their pain.
Combining these medications with adjunct options for breakthrough pain allows us to effectively treat pain without the risks and harmful side effects of prescribing opioids alone. Having an open discussion with our patients regarding reasonable expectations of pain relief, the importance of dosing schedules, and varied treatment options increases the odds of improved pain and decreases the chance of bouncebacks.
What else can we prescribe for pain?
Many patients can’t take acetaminophen or ibuprofen due to comorbidities, contraindications, or allergies, so what other options exist? Sometimes it’s as easy as getting back to the basics. Physical modalities such as heat or cold therapy can decrease pain by promoting circulation and altering nerve signals. Compression and elevation can significantly reduce swelling, which decreases pain. Knowing which modality to use in which phase of injury can be essential to help guide an effective pain treatment plan without the use of opioids.
Do topicals work?
Yes, topical pain medications can be an effective pain control method to add to a treatment plan. They’re low risk and have few side effects associated with them.3 These products deliver medication to a localized area of pain and may be used alone or as an adjunct to prescribed oral medications. The many delivery methods include gels, sprays, creams, ointments, and patches. The main classes are as follows:
- Counterirritants: These products contain ingredients like menthol, camphor, or capsaicin, which create a cooling or warming sensation. This overwhelms the nerves on the skin and distracts the brain from the underlying pain.
- NSAIDS: This medication works locally to decrease inflammation at the site, which can be helpful in the management of sprains and strains as well as chronic conditions like arthritis.
- Lidocaine patches: Lidocaine anesthetizes the area where the patch is applied. These patches can effectively manage localized pain, particularly nerve pain such as post-herpetic neuralgia.
What about nerve blocks?
Low-risk and highly effective nerve blocks can treat dental pain and headaches. This option gives clinicians a fantastic tool to quickly and easily alleviate a patient's acute symptoms. By combining short and long-acting anesthetics, you can effectively provide hours of pain relief or complete resolution of their pain. As urgent care clinicians, these skills are easy to learn, safe, and can be performed in the clinical care setting with minimal tools.4,5
Is there a place for opioids?
As we strive to meet best practice standards, we must realize that opioids may still have a role in treating pain. The pendulum has swung so far away from prescribing these medications that it is essential to remember our responsibility to treat our patient’s pain appropriately.
Many patients can’t take acetaminophen or ibuprofen, or perhaps their injury is severe enough that there may be some expected breakthrough pain even with adjunct medication. By having alternative medications or modalities available and educating our patients, we can decrease the amount of opioids prescribed and simultaneously improve patient care. Our patients are best served when we provide them with the safest and most efficacious treatments. As the landscape of pain management continues to evolve, we owe it to our patients to stay current on viable options for acute pain management and treating chronic pain.
For more on this topic, listen to Dr. Ross Cohen and Jackie McDevitt-Capetolla PA-C discuss “Non-Opioid Pain Medication Tips and Tricks” in a special Urgent Care RAP podcast segment recorded live at the UCA conference!
- Butler MM, Ancona RM, Beauchamp GA, et al. Emergency Department Prescription Opioids as an Initial Exposure Preceding Addiction. Ann Emerg Med. 2016;68(2):202-208. doi:10.1016/j.annemergmed.2015.11.033 PMID: 26875061
- Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial. JAMA. 2017;318(17):1661–1667. doi:10.1001/jama.2017.16190 PMID: 29114833
- Leppert W, Malec-Milewska M, Zajaczkowska R, Wordliczek J. Transdermal and Topical Drug Administration in the Treatment of Pain. Molecules. 2018;23(3):681. Published 2018 Mar 17. doi:10.3390/molecules23030681. PMID: 29562618
- Miller S, Lagrata S, Matharu M. Multiple cranial nerve blocks for the transitional treatment of chronic headaches. Cephalalgia. 2019;39(12):1488-1499. doi:10.1177/0333102419848121. PMID: 31084198
- Shauly O, Gould DJ, Sahai-Srivastava S, Patel KM. Greater Occipital Nerve Block for the Treatment of Chronic Migraine Headaches: A Systematic Review and Meta-Analysis. Plast Reconstr Surg. 2019;144(4):943-952. doi:10.1097/PRS.0000000000006059. PMID: 31568309