EDITOR'S NOTE: Special thanks to our guest blogger this week, Dean Meenach, MSN, RN, CNL, CEN, CCRN, CPEN, EMT-P. **
EMS providers must have a thorough understanding of pain assessment tools and options for acute pain management, especially with the recent focus on opioid abuse.
Appropriate management of acute pain is an integral part of prehospital patient care. Here are some important things for you to know to be an effective prehospital provider.
1. UNDERSTAND THE SCOPE OF THE PROBLEM AND YOUR OPTIONS AS A PROVIDER.
Relief from pain is a basic human right, and pain is a leading reason that people call EMS. The prevalence of pain specifically in the prehospital setting varies, with estimates ranging from 20% to 53%. [1,2] EMS professionals have a legal and ethical obligation to provide the level of care that would be offered by a competent healthcare professional within their scope of practice. This includes pain management. 
Adequate pain relief is known to minimize the anxiety and cardiac complications associated with acute pain.  However, as many as 43% of patients report insufficient prehospital pain relief. [5,6]
Undertreatment of pain in the prehospital setting, paired with the recent health industry focus on de-emphasizing opioid exposure, creates a need for EMS professionals to have a thorough understanding of pain assessment tools and the comparative effectiveness and safety of analgesics for prehospital acute pain management.
2. PREHOSPITAL PAIN MANAGEMENT BARRIERS INCLUDE TRADITION, PERCEPTION AND A GROWING RELUCTANCE TO ADMINISTER OPIOIDS.
Old thinking and clinical dogma remain major barriers in prehospital pain management. The pain experience remains a complicated phenomenon, with the perception and expression of pain mediated by complex psychological, social and environmental factors. 
A 2013 study focusing on the perceptions of paramedics regarding pain management reported the following:
- Reluctance to administer opioids to patients when objective signs of injury were lacking.
- Concern over contributing to opioid abuse and addiction.
- Confusion over their targeted pain goal.
- Fear of masking diagnostic symptoms.
- Disinclination of aggressive dosing of opioids. 
Paramedics are likely to observe significant interpersonal variations in the way patients express pain. Also, paramedics tend to rely on patient behavior as a means of validating the patient’s report of pain severity.  This can easily result in disparities in the quality of care if the patient’s pain-related behavior does not meet the paramedic’s expected perception.
The most well-known definition of pain was suggested by pain researchers McCaffery and Pasero two decades ago: “Pain is what the person says it is and exists whenever he or she says it does.”  However, while inclusive of the patient pain experience, many in the healthcare industry may be questioning the present application of this definition in light of the current opioid epidemic.
3. WHEN IT COMES TO NARCAN, MORE IS NOT ALWAYS BETTER.
One feature that makes opioids favorable for pain management in the prehospital setting is that Narcan (naloxone) readily reverses its effects. This can be important if respiratory depression or apnea occurs in a patient who is overly sensitive to an opioid or who inadvertently receives a higher-than-normal dose.
Although some opiate overdoses require large doses of naloxone, generally the use of initial large doses should be avoided. Instead, administer small doses and reassess if more naloxone is needed. Large doses can induce patient agitation, exacerbating other co-existing diseases; delay recognition of other emergencies; and compromise EMS provider safety. In addition, rapid opiate reversal caused by large naloxone doses can induce acute opiate withdrawal and precipitate severe cardiovascular, neurological and behavioral emergencies.
Another important characteristic of naloxone to consider is that its half-life is usually less than the half-life of most opioids. Therefore, administering naloxone and then treating and releasing (without transporting) is generally unsafe. [11,12,13,14]
4. USE A STANDARDIZED PAIN ASSESSMENT TOOL.
Like many other patient complaints, the evaluation of pain requires both subjective and objective assessments.  Since pain cannot be adequately treated if it is not appropriately assessed, careful use of a validated tool to measure pain in the prehospital setting is required. Current guidelines for the management of prehospital trauma pain recommend specific pain scales, broken into age-related categories. 
There are several types of tools used to assess pain severity. Some popular tools include:
- The numeric rating scale (NRS).
- The visual analogue scale (VAS).
- The verbal rating scale (VRS).
Protocols for prehospital pain management should specify at least one pain tool to measure the severity of pain. [17,18] When dealing with small children and infants, it is important to take into consideration their inability to adequately self-report pain. The medical director and EMS entity should decide which scale is best for the individual system.
5. KNOW THE ADVERSE EFFECTS AND BENEFITS OF DIFFERENT OPIOID PAIN MEDICATIONS.
Morphine sulfate has been used in the field for more than 40 years to treat chest pain that doesn't respond to nitroglycerin and many other types of pain. In many systems, the role of morphine is limited due to fear of the drug's potential adverse effects. These include respiratory depression, nausea, vomiting and hypotension.
However, morphine is safe and effective if it is carefully administered in a slow, controlled manner with frequent re-evaluation of the patient's pain and vital signs.
Fentanyl, a synthetic opioid, is also used in the prehospital setting. Many of its properties make it attractive for prehospital use. It has a short half-life, and unlike morphine, it does not cause the release of histamine and has few vasodilatory properties.
6. RECOGNIZE THE SIGNS OF OPIOID OVERDOSE.
In the United States, an alarming number of patients are addicted to opiate pain medications, which has sparked a significant increase in the number of deaths and near-death experiences involving narcotic medications (this includes those prescribed by a clinician and those obtained illegally by patients, as well as illegal street drugs, chiefly heroin). According to the CDC (2018), opioids remain the main driver of drug overdose deaths, resulting in over 47,000 overdose deaths in the United States in 2017. [19, 20]
Signs of opiate abuse may manifest in several ways. Recurrent encounters with the same patient always involving a complaint of pain, patients who receive narcotic pain prescriptions from several different healthcare providers and patients describing allergies to all pain medications that aren't narcotics may indicate chronic overuse of opiate medications or illicit drugs. Such patients may also have high tolerance levels for narcotic pain medications.
Physical exam findings that may be consistent with opiate use can include constricted pupils, and, if injecting the opiates, there may be chronic scarring of the injection sites that follow the paths of veins (track marks). Most commonly, track marks occur in the arms and the feet, occasionally in the groin.
While prehospital care providers shouldn't automatically withhold narcotic pain medications to those suspected of or admitting to chronic use or abuse, EMS must be particularly vigilant for signs of troublesome effects, such as respiratory depression.
7. CONSIDER NEW APPROACHES FOR PREHOSPITAL ACUTE PAIN MANAGEMENT.
The ultimate prehospital pain medication would have rapid onset, short duration of action and minimal or no adverse effects. Unfortunately, such a medication does not exist. When using pain medications, EMS providers must evaluate the risks and benefits of each medication.
Paramedics should be skilled at implementing pharmacological and non-pharmacological treatments to alleviate the patient’s pain. Clinical practice guidelines generally list several drugs indicated for the treatment of pain. The choice of drug is based on pain severity, available routes of administration and patient history that may reveal contraindications to particular therapy.
Remember – although there may be contraindications to specific pain medications, there is no contraindication to analgesia.
Pharmacological options for analgesia:
- Nitroglycerin (coronary vasodilator for chest pain).
- Morphine (narcotic/opioid).
- Fentanyl (synthetic opioid).
- Dilaudid (hydromorphone) (synthetic opioid).
- Toradol (ketorolac) (anti-inflammatory).
- Nitronox (nitrous oxide) (gas analgesic).
- Intravenous acetaminophen (Ofirmev) (CNS depressant).
- Ketalar (ketamine) (dissociative anesthetic).
In recent years, ketamine has shown promise in pain management. A recent study showed a significant reduction in pain and lack of clinically significant adverse effects when low-dose IV ketamine was used compared to IV fentanyl. 
Non-pharmacological options for analgesia:
- Distraction (conversation, music, video games, etc.).
- Age appropriate interventions for infants and children (rocking, cuddling/swaddling, pacifiers, patting, etc.).
8. ADMINISTER MEDICATION WITH BEST PRACTICES IN MIND.
In 2005 the Joint Commission published a study that identified poor or incorrect medication administration practices as the cause of medication errors that resulted in many of the unpleasant side effects of narcotics analgesics. [22,23,24,25] These include nausea, vomiting, dizziness, diaphoresis, hypotension and even rapid development of respiratory depression or apnea. 
Since bolus injections are associated with an increased risk of chemical phlebitis, many healthcare professionals dilute the medication in 10 ml of sterile 0.9% normal saline and push over three to five minutes. Diluting the narcotic analgesic makes it much easier to push slowly, as 10 ml of fluid is easier to push slowly than 1-2 ml as most narcotic analgesics are supplied.
9. DON’T QUESTION YOUR PATIENT’S VERACITY.
Many healthcare professionals are questioning McCaffery and Pasero’s (1999) definition of pain (what the person says it is whenever he or she says it). However, as healthcare professionals, paramedics have an ethical obligation not to question their patient’s veracity (truthfulness) without objective evidence to have concern about their clinical decision to treat pain.
In these circumstances, paramedics who withhold analgesia may place the patient at risk of inadequate care. In most states, it is recognized that healthcare professionals have an ethical and legal obligation to treat pain.
Paramedics may have concerns that some patients reporting pain are seeking opioids for nontherapeutic reasons.  Because patient history is often inadequate to make this determination in the field, it is difficult to discriminate between behavior associated with opioid addiction and behavior associated with pain.
It is often observed that some patients may even ask for analgesics by name when they know which drugs are most effective in relieving their pain. It has been well-known for decades that patients seeking analgesics for unrelieved pain may be physically dependent on analgesics to relieve their pain. This is known as pseudo-addiction and is not evidence of actual addiction. 
10. PAIN IS AN ONGOING ISSUE FOR EMS PROVIDERS.
The opioid crisis has raised questions about the best way to address patients’ pain, both in the hospital and in the field. This dilemma has been compounded by recent confusion raised by the authors of influential federal guidelines for opioid prescriptions for chronic pain.
A recent article published by the New England Journal of Medicine (2019) reported that doctors, state and federal agencies, insurance companies and others in the healthcare system had wrongly implemented the CDC recommendations and “cut off” patients who should have received pain medication. 
Pain management doctors and patient advocacy groups have long maintained that strict limits on prescriptions were leaving patients who had been on stable opioid dosages for years unable to stay on their regimens and sometimes pushed them to illicit opioids or even suicide. 
Although there’s no evidence tying EMS administration of narcotics to addiction or overdose deaths, finding alternatives to managing pain could reduce the amount of opioids given in the field. At the same time, it is critical that patients’ pain is not ignored and that safe and effective treatments are available to and administered by EMS providers.
1. Chang, H., Daubresse, M., Kruszewski, S. P., & Alexander, G. C. (2014). Prevalence and treatment of pain in EDs in the United States, 2000 to 2010. The American Journal of Emergency Medicine, 32(5), 421-431. doi:10.1016/j.ajem.2014.01.015
2. McLean, S. A., Maio, R. F., & Domeier, R. M. (2002). The epidemiology of pain in the prehospital setting. Prehospital Emerg Care, 6(1), 402-405.
3. Cousins, M. J., & Lynch, M. E. (2011). The Declaration Montreal: Access to pain management is a fundamental human right. Pain, 152(12), 2673-2674. doi:10.1016/j.pain.2011.09.012
4. Thomas, S. H., & Shewakramani, S. (2008). Prehospital Trauma Analgesia. The Journal of Emergency Medicine,35(1), 47-57. doi:10.1016/j.jemermed.2007.05.041
5. Jennings, P., Cameron, P., & Bernard, S. (2009). Measuring acute pain in the prehospital setting. Acute Pain,11(3-4), 153. doi:10.1016/j.acpain.2009.10.023
6. Werner, S. (2005). Few Emergency Medical Services Patients With Lower Extremity Fractures Receive Prehospital Analgesia. Annals of Emergency Medicine, 46(4), 389-390. doi:10.1016/j.annemergmed.2005.08.019
7. Craig, K. D. (2015). Social communication model of pain. Pain, 156(7), 1198-1199. doi:10.1097/j.pain.0000000000000185
8. Walsh, B., Cone, D. C., Meyer, E. M., & Larkin, G. L. (2012). Paramedic Attitudes Regarding Prehospital Analgesia. Prehospital Emergency Care, 17(1), 78-87. doi:10.3109/10903127.2012.717167
9. Jones, G. E., & Machen, I. (2003). Pre-hospital pain management: The paramedics’ perspective. Accident and Emergency Nursing, 11(3), 166-172. doi:10.1016/s0965-2302(02)00219-9
10. McCaffery, M., & Pasero, C. (1999). Pain: Clinical manual. St. Louis, MO: Mosby.
11. Faul, M., Lurie, P., Kinsman, J. M., Dailey, M. W., Crabaugh, C., & Sasser, S. M. (2017). Multiple Naloxone Administrations Among Emergency Medical Service Providers is Increasing. Prehospital Emergency Care, 21(4), 411-419. doi:10.1080/10903127.2017.1315203
12. Lameijer, H., Azizi, N., Ligtenberg, J. J., & Maaten, J. C. (2014). Ventricular Tachycardia After Naloxone Administration: A Drug Related Complication? Case Report and Literature Review. Drug Safety - Case Reports,1(1). doi:10.1007/s40800-014-0002-0
13. Wampler, D. A., Molina, D. K., Mcmanus, J., Laws, P., & Manifold, C. A. (2011). No Deaths Associated with Patient Refusal of Transport After Naloxone-Reversed Opioid Overdose. Prehospital Emergency Care, 15(3), 320-324. doi:10.3109/10903127.2011.569854
14. Willman, M. W., Liss, D. B., Schwarz, E. S., & Mullins, M. E. (2016). Do heroin overdose patients require observation after receiving naloxone? Clinical Toxicology, 55(2), 81-87. doi:10.1080/15563650.2016.1253846
15. Bounes, V., Barniol, C., Minville, V., Houze-Cerfon, C., & Ducassé, J. L. (2011). Predictors of pain relief and adverse events in patients receiving opioids in a prehospital setting. The American Journal of Emergency Medicine, 29(5), 512-517. doi:10.1016/j.ajem.2009.12.005
16. Gausche-Hill, M., Brown, K. M., Oliver, Z. J., Sasson, C., Dayan, P. S., Eschmann, N. M., . . . Lang, E. S. (2013). An Evidence-based Guideline for Prehospital Analgesia in Trauma. Prehospital Emergency Care, 18(Sup1), 25-34. doi:10.3109/10903127.2013.844873
17. Marquié, L., Raufaste, E., Lauque, D., Mariné, C., Ecoiffier, M., & Sorum, P. (2003). Pain rating by patients and physicians: Evidence of systematic pain miscalibration. Pain, 102(3), 289-296. doi:10.1016/s0304-3959(02)00402-5
18. Solomon, P. (2001). Congruence between health professionals' and patients' pain ratings: A review of the literature. Scandinavian Journal of Caring Sciences, 15(2), 174-180. doi:10.1046/j.1471-6712.2001.00027.x
19. Scholl, L., Seth, P., Kariisa, M., Wilson, N., & Baldwin, G. (2018). Drug and Opioid-Involved Overdose Deaths — United States, 2013–2017. MMWR. Morbidity and Mortality Weekly Report, 67(5152). doi:10.15585/mmwr.mm675152e1
20. Centers for Disease Control & Prevention (CDC). (2018, July). Drug overdose deaths. Retrieved July 09, 2019, from https://www.cdc.gov/drugoverdose/data/statedeaths.html
21. Bronsky, E. S., Koola, C., Orlando, A., Redmond, D., D'huyvetter, C., Sieracki, H., . . . Bar-Or, D. (2018). Intravenous Low-Dose Ketamine Provides Greater Pain Control Compared to Fentanyl in a Civilian Prehospital Trauma System: A Propensity Matched Analysis. Prehospital Emergency Care, 23(1), 1-8. doi:10.1080/10903127.2018.1469704
22. Alexander, M. (2016). Infusion Standards. Journal of Infusion Nursing, 39(4), 181-182. doi:10.1097/nan.0000000000000181
23. Gabriel, J. (2008). Infusion therapy part one: Minimising the risks. Nursing Standard, 22(31), 51-56. doi:10.7748/ns2008.04.22.31.51.c6445
24. Gorski, L. A. (2007). Infusion Nursing Standards of Practice. Journal of Infusion Nursing, 30(3), 151-152. doi:10.1097/01.nan.0000270673.13439.95
25. Lavery, I., & Ingram, P. (2008). Safe practice in intravenous medicines administration. Nursing Standard,22(46), 44-47. doi:10.7748/ns2008.07.22.46.44.c6600
26. Santell, J. P., & Cousins, D. D. (2005). Medication Errors Involving Wrong Administration Technique. The Joint Commission Journal on Quality and Patient Safety, 31(9), 528-532. doi:10.1016/s1553-7250(05)31068-3
27. Weissman, D. E., & Haddox, D. J. (1989). Opioid pseudoaddiction — an iatrogenic syndrome. Pain, 36(3), 363-366. doi:10.1016/0304-3959(89)90097-3
28. Dowell, D., Haegerich, T., & Chou, R. (2019). No Shortcuts to Safer Opioid Prescribing. New England Journal of Medicine, 380(24), 2285-2287. doi:10.1056/nejmp1904190
About the author
Dean Meenach, MSN, RN, CNL, CEN, CCRN, CPEN, EMT-P, has taught and worked in EMS for more than 24 years. He currently serves as an advanced nurse clinician and EMS program director at Mercy Hospital South in St. Louis, Missouri. He has served as a paramedic instructor/program director, Paramedic to RN Bridge Program instructor, subject matter expert, author, national speaker and collaborative author in micro-simulation programs. He can be reached at email@example.com.