This Page Intentionally Left Blank - Int Medical

66 NSAIDs and opioids
well-demonstrated fact that higher morphine doses are usually required
for ED pain control. 19 In fact, data demonstrate that for children and adults,
with a variety of medical and surgical conditions, 0.1 mg/kg IV morphine is
unlikely to constitute adequate analgesia. 19,20 Ceiling doses of opioids will
vary by drug and patient, so a specific “abandonment point” cannot be
delineated. Rather, we advise the ED clinician to keep in mind that safety,
efficacy, and ease of titration are optimized by giving one opioid a fair trial
before switching to another.
On a related point, even when morphine is written in a correct initial
dosage (i.e. in a range 0.1–0.15 mg/kg), well-intentioned providers often
mistakenly administer the drug in staggered fashion, giving multiple (nearhomeopathic)
1–2 mg injections over an extended time period. Such caution
is encouraged when opioids are given to patients particularly likely to experience
side effects, but the vast majority of ED patients in severe pain can
easily tolerate a 4–6 mg initial morphine dose. In fact, savvy ED clinicians
discussing hydromorphone’s advantages have noted that the drug’s apparent
incremental efficacy over morphine is simply a function of it being administered
as ordered (i.e. in a single 1 mg dose), rather than split into aliquots as
morphine often is. 16
While a few doses of opioids given in generally recommended ranges are
unlikely to cause serious side effects, it is our experience that nausea and
vomiting are common, especially with aggressive opioid dosing such as
advocated for many conditions in this text. We do not believe that prophylactic
administration of antiemetics should be routine, but we do advocate
early administration of such medications in patients who have a history of
opioid-associated nausea. The ED provider should also be observant for, and
quickly treat, nausea and vomiting that occur after opioid administration.
Otherwise, many patients will find the side effects of the analgesia as unpleasant
as, or worse than, the pain itself.
We believe that the systemic use of opioids in pregnant patients is often
associated with favorable risk-to-benefit ratio. Most opioids are FDA
Pregnancy Category C, although there are some exceptions such as oxycodone
and nalbuphine which are Category B. Long-term use of opioids, especially
during the peripartum period, increases the risk of opioid use during