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The practice of medicine cannot be in a vacuum. There are instances where pain is truly severe – so severe that taking alternative pain medications to opioids will not cut it. In these instances of acute pain, the pain is expected to subside in a matter of a days. As medical practitioners, we cannot simply ignore reality and turn a blind eye to extreme pain in an acute setting.
When it comes to traditional opioids, that may be all it takes to develop a dependency that can ultimately lead to an addiction. There are precautions one can take to mitigate the risk posed by conventional opioid pain medications if other alternatives do not work, while still being considerate of the severity of the pain.
Ketorolac
This is an older medication that many may know of as “the shot” that professional athletes (especially football players) get on the sidelines after an injury that allows them to get right back into the game. It is an anti-inflammatory equivalent to 30mg of morphine. It is not, however, a relative of any opioid, but rather a nonsteroidal anti-inflammatory drug (NSAID). It is given as an injection either into the muscle or through an IV, thus making it extremely effective in the emergency room for immediate pain relief. As an outpatient, an intranasal form was developed called Sprix. It comes as a 5-day supply of nose sprays with each “puff” being carefully dosed to give the proper amount of medication. It is so powerful, in fact, that the most a person can take it for is 5 days; after that, the medication will begin to cause erosion of the lining of the stomach.
Oral Steroids
These are very popular in other parts of the world outside the U.S. for treating acute pain. By nature, steroids are anti-inflammatories and are commonly prescribed by physicians for a variety of conditions, particularly chronic ones. These are not the same steroids taken by athletes or bodybuilders and do not carry the same types of side effects. Due to their impact on the body, one cannot simply start and stop taking these at will; they need to be tapered up and then tapered back down. For pain, they are prescribed as a “dose pack” or a “Medrol dose pack” and are dispensed in a blister package with the pills for each day neatly organized to take the guesswork out of the equation. Over prolonged periods of use, they can cause weight gain, acne, water retention, irregular hair growth; however, in the acute setting these are less likely to happen.
Tramadol
This is a pain medication in the opioid family, but with less potency and addiction potential as traditional opioids like Oxycontin. A 50mg dose of tramadol is equivalent to approximately 10mg of oxycodone. It works on some of the same receptors in the body as an opioid, but also works on other receptors to block pain (norepinephrine and serotonin). This allows it to treat pain by targeting multiple pathways, rather than just opioid pathways. While it is not the same strength as something like fentanyl or oxycodone, it does have addiction potential. In the acute setting, tramadol may be a good compromise for someone in severe pain where other methods are not working.
Nucynta
This is a “cousin” of tramadol, also known as tapentadol. It has a similar overall method of action to tramadol, but is more potent. Like tramadol, it works on some of the same receptors in the body as an opioid but also works on other receptors (primarily norepinephrine) to block pain. Like tramadol, the addictive potential of Nucynta is less than that of something like oxycodone, but also carries addiction potential. The maximum dosage that one can take in a 24-hour period is 600mg.
Even in situations where the pain is severe, traditional opioids can still be averted by using less potent medications when alternatives are not effective in treating pain. While Tramadol and Nucynta can cause dependence, it is not something a physician would expect to see when prescribing for short-term acute pain. Individuals and family members in recovery should avoid these medications if possible and speak with an addiction medicine professional for pain management needs.
As a reminder, be sure your child carries an identification card or bracelet if using medication-assisted treatment for opioid use disorder and shares his or her history and current medications with all providers.
Please note that the Partnership to End Addiction does not endorse any of these procedures or medications. We always advise discussion of any medication or other treatment with your physician.