Does toradol have codeine in it

30f 4’11 64kg
Diagnosised: chronic migraines since age 8
Current medications: birth control, qulipta, diclofenac potassium, rizatriptan
Current location: Australia
Supplements: magnesium, b12, d3
No smoking, no drugs, no drinking
Hello! About once or twice a year I get an intractable migraine that does not go away with my regular abortive meds (the diclofenac and rizatriptan). I am from the states and the last few years when this happens I’ve gone to urgent care to get a toradol injection. It has worked and stopped the migraine every time. I am now in Australia and my last intractable migraine was over a year ago- I’m also on a new preventive but I missed a few days and I think that’s what triggered this migraine.
So on day 4 of this I went to a gp who told me they don’t do toradol injections in Australia and gave me codeine plus ibuprofen. I tried it and it dulled the pain but within 4 hours pain was back to a 10. I’m on day 6 now. This migraine could last anywhere from 2-6 weeks without the toradol to stop it.
I did ask the gp what my options are if it doesn’t help and he said I should go hospital I’d like to avoid that as I don’t have good insurance and will be paying out of pocket for whatever dr I see. Is the toradol or something similar really not an option here? I don’t know what to do or how to ask or who to ask for what I know will work for me.
I can’t think straight and I’m losing my mind at this point lol, any advice is very much appreciated

On the 6th i felt a familiar twing in my low back that normally means I'm about to have some extreme sharp stabbing low back pain for a few days. This has been happening to me since i was 25, so about 10 years now. Normally i can just take it easy but continue my normal life and just deal with the sharp pain, but this time is different.
I dealt with the pain until Monday and got a toradol and steroid injection from my pcp. It felt better the next day, but then it started to get worse. Much worse. By Friday, so a week after it started, I can't sit or stand properly for very long. And now Sunday, i can barely stand or walk.
I have an MRI next week but i need to know what works for others until then? Codeine is doing nothing, ibuprofen does nothing, naproxen does nothing. I've tried stretching, hot showers, they gave some temporary relief, but it didn't last. I know I'm supposed to move around so it will not get stiff, but how do i do that with it hurting so bad i can barely walk?

So Wednesday I went into the ER for extreme pelvic pain. I thought it was related to my reproductive system since I also struggle with endometriosis, however I’m mid-cycle so I had a feeling it was more than just that. Also dealt with an ovarian cyst when I was 13 that went away on its own. I mentioned that and they didn’t seem too concerned since I didn’t exhibit that I was dealing with a lot of pain (I’ve gotten good at concealing my cramps/endometrial pain). They set me up on an IV with a dose of toradol, which did basically nothing. Bloodwork and urinalysis came back clear so I went in for a CT scan. This is when my pain was at its worst. Afterwards I spent about 10 minutes in the ER until the nurse came back with morphine. That’s when I knew it was something serious and the dr came in to inform me that I had a 7mm stone passing through my ureter. The morphine did wonders and I essentially felt back to normal. Got sent home with 30/350mg codeine and tylenol, ondansetron, and another med to dilate my urethra (I think?) while I awaited a urologist to contact me. After the morphine wore off, I took the meds they gave and immediately felt super nauseous. I ate beforehand and took all meds as instructed. The next day was absolutely horrible, pain and nausea were at 100 so I left work early and back to the ER I went (I didn’t drive myself). Then the same routine with IV and toradol, no morphine this time. Another doctor looked at my prescriptions and gave oxycodone, 5/325mg with tylenol. Almost everyone’s posts I read says that toradol does wonders for them. I’m not having the same experience. Even with 800mg ibuprofen I don’t get a whole lot of relief. The oxy actually does help reduce the pain but with the amount of acetaminophen I can’t take a dose without wanting to throw up my body inside out. I want to mention this to a doctor to see if I can get the oxy dosage up a bit but I don’t want to come across as drug-seeking (excuse the username, I made this account as a 17 year old stoner and opioids are definitely not my drug of choice lol). I’m still awaiting a call from a urologist. The ER dr I spoke to said that women have issues passing stones over 5-6mm and since mine is a 7 I may need a procedure to have it removed. I know nausea also comes with kidney stones but this amount is crazy and I hate having to choose between the stabbing, searing pain and having to sit in front of a toilet or have a trash bag nearby constantly. Anyone have any advice?

I have chronic migraines, my moms side has them so myself, my mom, and brother have them. my mom is prescribed tramadol and fioricet. my brother takes rizatriptan it doesnt help me really. ive taken my moms tramadol and its no help honestly none at all. her fioricet wasnt too helpful but her fioricet with codeine in it gave me relief however i dont use it because its her prescription.
As i mentioned i have epilepsy so ive been on zonegran, topamax, magnesium, lamotrigine, aimitriptyln, gabapentin, propranolol, nortriptyline, and qulipta. ive also tried the all the over counter pain relief and the migraine reliefs none seems to work.
I am on keppra now and it helps my seizures definitely its been a life saver since ive tried so many drugs before it. although it’s been causing constant migraines that are unbearable sometimes they are so bad i cant feel my seizure aura. When i went to the ER i was given phenergan, benadryl, and toradol. it was a life saver. I’ve been on keppra since September and its been better than all the other seizure meds ive taken.
My neurologist tried to prescribe me toradol but they said it was discontinued so i was prescribed ketorolac which i took with phenergan and benadryl. It worked fine but not like the injection did at the ER. Usually he gives me zofran but it causes headaches and constipation like hell.
Does anyone have any recommendations I see my neurologist tomorrow and he’s lost too because we’ve tried so much. My insurance doesnt accept any injections like ajovy sadly.

I just had a conversation with my GP yesterday re: pain management. I've been taking Tylenol #3 for last about 20 years of my life, and at some times, Tylenol #1. I recently started taking toradol several years ago. Over the counter medication does not work, and I have had no luck with triptans.
I needed a refill on my t#3, and my script says "1-2 tabs once daily". It has been no where near enough. Even with the prevention meds, I found that my migraines have been unresponsive to the Tylenol #3 and toradol, thus needing more, but in the process, extending my migraine. I requested an increase in the amount I can take/day.
I relayed this to my GP, and he believes that it's the codeine that's causing my migraines/making them worse. We decided to not refill the script and he is going to do some research on other migraine treatments. I have a few t#3 stashes hidden away everywhere that I still need to finish up, but then that will be the end.
I guess it's like, I've been taking it for 20 years and now I'm going to have to come clean. I know it's going to be hard and the withdrawal isn't going to be pretty (I've had a fair few in my life already). I hope this works.
If you read this far, and take pain medication, what do you take (if you don't mind sharing)? Just so I have an idea of what he might suggest next week.

This is a long one, so buckle up, y'all. TLDR at the end.
So, I (28M) am white. Like really, really white with a red leprechaun beard and all. My girlfriend (23F) is also really white (no red beard, fortunately). Last week on Tuesday we decided to get away for a bit and drove to a neighboring town to stay in a quaint little AirBnB to spend a few days meeting up with an old friend or two that live in the area, go kayaking or do something nice outside, and then go to a nice restaurant.
We get to the AirBnB Tuesday night, sleep-in the next morning, and meet up with one of her guy friends who wants to check me out and make sure I'm good enough for her (we've been together 6 months, already live together, and things are going swell). We have brunch, have great conversation, and go to a comic book store across the street to check out some comic books and board games. We have a nice time talking about nerdy stuff, I pass the guy friend test, and we part our ways for the day.
There's all kinds of water in the area (springs, lakes, rivers), so we're looking to do fun water stuff. We got a recommendation from a friend to do a short 1 mile hike to a little spring area that's well reviewed but not crowded, so we go and swim around, have a really nice time, and it's cloudy and shaded, so no big deal for us pasty whites (I know. UV rays go through clouds, so we still need sunscreen. Keep your pants on.). After we hike back to the car, we drive back to our little AirBnB, clean up and decide to plan out our next day. We wanted to go jetskiing and/or kayaking, but jetskiing was all booked up. I used to be a river rafting guide and sea kayaking guide, years ago. I really miss it and was getting pumped up for a chance to get out on the water. So, selfishly, instead of booking the 2-3 hour (6ish miles) river trip meant for families and young, easy-going couples like us, I book the full day 14 mile trip...for my girlfriend that doesn't even really know how to paddle... But I used to do this professionally and train people how to do it, so no big deal, right?...right?
We get a cooler, fill it with ice, beer and water (priorities in order here folks), a few sandwiches and some candy and granola bars. Everything you need for a great day on the river. I throw our phones and valuables in my trusty dry-bag from my years of guiding that I never get to use anymore, and load everything up into the car. We get to the river company half an hour early before the owner is even there, and I realize I left the sunscreen in a backpack back at the AirBnB, so we rush the half mile back to the house. I grab the backpack, throw it in the trunk, and we get back to the river company with 20 minutes to spare. The owner shows up, we load up in the van, and he starts to drive us to the put-in, 14ish miles up-river.
The owner and I talk about the river business and how the pandemic has impacted it all in general. I tell him about my previous guiding experience around the states, so he says he's confident in our ability to paddle this easy Class 1 river. Once we reach the put-in, I help him get the kayaks in the water, I clip the dry-bag and cooler to the back of my kayak, and we say, "see ya down river!" My girlfriend and I push out, and we're off! Here we go for a perfect day on the river. Just me, my wonderful girlfriend, and nature...
A few minutes after the owner drove off and we're a good way down-river from the put-in, my girlfriend asks, "Hey babe, can you grab me the sunscreen?" The sunscreen... Right... I put that in...where did I put it... It's in the backpack... The backpack...that's in THE FUCKING TRUNK OF THE CAR, FOURTEEN MILES AWAY. My idiot ass didn't think to switch the sunscreen from the backpack in the trunk to the dry-bag I was bringing with us on the river. I was so pumped and ready to go that it didn't cross my australopithecine, mandarin orange sized brain to switch that little bottle of white lotion from one bag to the other. I'm trying not to panic because we are past the point of no return. Rivers are typically a one way street unless you have a motor-powered propellor. Our ride is gone, and there's no place for us to stop and meet up with him to pick up the crucial piece of protection that our delicate skin desperately needs from an unforgiving star so bright and powerful that humans across the globe worshipped it for millennia as a fucking god. We are both white as fuck, burn easily, and are mother nature's top candidates for skin cancer. The sun-god frowns upon our existence and reminds us that however socially privileged we are, we are feeble, too undeserving to bask in its radiance, and should retreat to the dark and cold climates from which our genetics evolved to inhabit (I'm talking about air-conditioned buildings here).
I proceed to profusely apologize to my girlfriend and say what an imbecile I am and an asshole for being so selfish by getting us into this whole debacle. My girlfriend is one of the sweetest, most patient, most forgiving people on this planet. She tries not to panic herself, so we both take the stoic approach and deal with the reality at hand. We can enjoy what we have of the day and accept the situation, or we can scream and fight and still have to paddle 14 miles pissed at each other. We decide to do the former. I teach her some basic paddling strokes, proper technique so she doesn't overexert herself or strain a muscle, and I try to take it slow so she can keep up. Once we get going, I start paddling a normal pace for myself, getting into a steady, meditative rhythm, and a minute later she's 40 yards behind me. So I stop, call out a little helpful instruction, and wait for her to catch up. She catches up and I start paddling again. Same thing happens, again and again, for hours. Now, my self-centered ass is getting a little frustrated because I wanted a nice day of meditative paddling like I used to do, but I've got to sit in place for most of it and just wait on my girlfriend to catch up every 5 minutes because she can't get the hang of it and keep up. I try to be as helpful and patient as I can in showing her how to paddle efficiently, but nothing was sticking. I'm also getting a little worried because they close up shop at 5, and I'll get charged extra for every half hour we're on the water past closing time. I didn't think we were going to make it.
Within the first 3 hours, she gets swept out of her kayak; once by a tree, another not long after by a quickly bending current. She panics, heroic expert paddler boyfriend swoops in and saves the day, twice. Look at me, I'm a badass. We resume the former pattern. About hour 2 is when I started to feel a burning sensation on the tops of my legs. In my head, I know this is going to SUCK. I've had my share of bad sunburns before. Not my first rodeo. But I had NO idea what was to come. It is 95 degrees, not a cloud in the sky, and we are on the water for SIX HOURS. Suffice it to say, my girlfriend is visibly upset and not happy with me nor our situation. She didn't really know what she was signing up for when I said 14 miles. When we finally make it to the take-out, I carry the kayaks back to the little shed by the owner who briefly looks at my face, then immediately down at my legs. "Wow... that's a pretty bad burn," says this evenly bronzed water-man. I replied, "Thanks for a great trip. Can't wait to come back," and got the fuck out of there as fast as I could. I was so embarrassed after all the talk of my badass experiences in the deserts of west Texas, Utah, and the lush green forests and glacial blue waters of the Pacific Northwest.
My girlfriend and I drag ourselves to the car, ease our now lobster red, crusted skin onto the black fabric seats that have soaked up the sun, and gun it back to the AirBnB for cold showers. After we're all rinsed off, we gently dab dry whatever water that hadn't immediately evaporated off of our feverish skin. I lie down on the bed and immediately start presenting symptoms of sun-poisoning. I'm nauseous and uncontrollably shaking. My legs, face, and neck are blazing while my covered torso was freezing. A complete imbalance of thermoregulation. My own Superwoman makes a run to the grocery store to get us some aloe and whatever burn lotion she can find while her little bitch of a boyfriend writhes around on sheets rougher than he's spoiled to back home. She gets back, we lather up with aloe, and spend the whole night nauseous, burning, and shivering. There's no way we could dress up now and go out to that nice restaurant, built on a cliffside overlooking a beautiful lake. Everything burns and hurts to the touch, and we feel like shit. So, we sleep through the shakes, clean the place up in the morning, and hit the road. The burning and stinging just gets worse by the minute, and I can't stop apologizing. My girlfriend holds this boundless vat of forgiveness, despite her pain and frustration. She strokes my hair, kisses me, and says it was just a mistake and it's not my fault. She gently holds my hand as I drive us back home, and she drifts off to sleep.
One day later (Friday) we are so badly burned that we can hardly walk. Any kind of movement is difficult and painful because burnt skin just dries and tightens up. Add swelling to that and it's even worse. We both work nightshift in direct patient healthcare on the weekends, so we call in to our bosses because there is no way in hell that we can work like this, or even wear clothes besides underwear. We start taking 800mg of ibuprofen (the max prescribed dose) to help with swelling and pain which does absolutely nothing. I text my mother because I know she has a whole pharmacy of controlled substances in her bathroom cabinet from previous surgeries and lower back issues that she has saved for a rainy day (sunny in our case). Vicodin for the win! She sends my dad over with a bottle full of that shit, and we start a proper pain relief regimen every 4-6 hours per the instructions on the bottle.
So, I decide to just push through the pain. Come this past Sunday, we are in agonizing pain and decide that maybe it's time to go to the urgent care clinic. (I had to cancel a promising second interview because I couldn't wear pants or walk without limping.) The doctor takes us both in the same room, briefly and quickly looks us over and says "yeah that's a severe burn". She prescribes my girlfriend tramadol for pain and zofran for her nausea. For me... I get ibuprofen. The same shit I've been taking at the same dose, just in single pill form. She sends in a nurse to give us a shot of toradol (same family as ibuprofen) to tie us over for the day. When the MA comes to give us our work excuses and prescription papers, I ask her why the doctor didn't prescribe me the same thing as my girlfriend or any kind of actually effective pain relievers. She goes to check with the doc, comes back and says "she won't explain why. Sorry." If I press for an answer, I'll come across as "drug-seeking" and not only won't get the pain meds but will probably put a red flag on my medical chart for future reference. So we take our papers, limp and shuffle to the pharmacy, pick up our meds, and drive home. I stop taking the Vicodin because I have that promising interview I rescheduled coming up. If I get the job, I need to pass the drug test, and opiates will pop up for which I don't have a prescription as an excuse.
Over the next few days, despite taking my mom's "repurposed" hydrocodone, the pain gets worse and worse, to the point where our bones are aching. We get random "stings", without warning, anywhere on the burn sites where it feels like a wasp is digging its ass into your subcutaneous tissue (I'm getting one now. FUCK.). These stings then turn into what feels like someone hammering a nail straight into your bone and then tapping it repeatedly just to screw with you (get it? Nail? Screw? Nevermind.). For some reason, I got a worse case of it than my girlfriend. My ankles and feet swell up so much that I can't really flex my feet anymore or properly extend my legs, and I'm getting puffy skin with rolls (I'm a tall skinny guy with usually visible veins and tendons).
Yesterday (Wednesday), I couldnt stand for more than a couple of minutes without severe pain. The burn is so deep that it has affected all the tissues beneath the epidermis. It feels like someone is whacking my shins with a sledgehammer the moment I put my feet on the ground, so we decide to go back to the urgent care clinic, where they inform us it will be at least a 4 hour wait. I'm grunting/moaning and keeling over in pain, scrambling for any surface I can hold onto to take the weight off of my legs. We're in a crowded place with a bunch of other sick people and crying children, and the receptionists behind the desk drop what they're doing and are running to get me a wheelchair. I looked and sounded that bad. I'm prideful, so I grit my teeth and decline the wheelchair. I'm 28 and relatively fit, not 75 and circling the drain. They see that I'm in so much pain that they quickly and quietly refer me to a sister clinic on the other side of town that opens up in a couple of hours with no wait once it opens. I'll get seen much faster. My girlfriend is driving all this time and is basically carrying me around, just bearing all the pain she's in herself. She's the fuckin GOAT.
We kill some time with Chipotle and Starbucks drive-thru, haul across town, and wait for this place to open. Once we're in, the receptionists take one look at me and immediately offer water and an ice pack that covers 1/16th of my total burn surface area. A nice gesture, but a laughable one. They get us in the back, and a middle aged, disgruntled, retired military LVN checks my vitals, and puts me in a room. A recently graduated PA walks in the room and actually does an adequate assessment of my burns and covers a thorough medical history (I eat a handful of pharmaceutical Skittles twice a day for unrelated chronic issues). Apparently PAs can't prescribe hydrocodone, so she puts me on codeine/Tylenol for pain, a diuretic to reduce the edema in my legs and feet, and an antibiotic in case I get an infection because apparently "that burn is not healing at all." We go home, and I hobble back to the apartment and out of the sun as fast as I can. So here I am, sitting on my couch, unable to sleep because of the pain, writing this long story that probably won't be read in full, and my legs are still being hammered with half-molten nails. Apparently the only thing that actually helps with this type and level of pain is hydrocodone. Even that doesn't kill it all.
Suffice it to say, I have learned my lesson. I am an arrogant, egotistical, self-centered dunce who is arguably the luckiest guy around to have a girlfriend that loves him despite his negligence, causing her severe damage to her skin and unimaginable pain, and is willing to do whatever she can to help her boyfriend get back to a healthy and pain-free state. Never forget the sunscreen, people. Have it around at all times and protect your skin, no matter your complexion or the amount of melanin with which you are endowed. Your skin is the largest and most exposed organ in your body that protects all the others and is easily and irreversibly damaged. It's not worth the pain in the short or long term and the potential of skin cancer in the future. Don't be a dumbass like me, and don't be fooled. The sun may shine it's glorious light upon you, but it will hurt like hell if you are really white and stay in it longer than 15 minutes without proper protection or covering.
TLDR; Took my gf on an all day river trip. Forgot the sunscreen. Got absolutely fried and are in an insane amount of pain a full week later despite 2 doctor visits, prescribed pain meds, and multiple bottles of aloe and lidocaine. I done fucked up.

Ever since I started my period at 12 I had painful periods. I was on and off birth controls a couple times, until now at 22. Started taking norethindrone and haven’t had a period since Jan of last year.
I’ve been in the hospital twice in the past 2 months because I was in such severe pain, no amount of over the counter naproxen would help. I wasn’t even really bleeding but it felt like the worst period of my life. Even the prescribed Toradol isn’t enough to help sometimes, the only thing that really works is Tylenol 3/codeine.
I’ve had many ultrasounds and tests and the only thing that’s ever come up is an ovarian cyst.
My GP is thinking endo and has referred me to an endometriosis specialist, as the gyno I see isn’t willing to do surgery. The only option the gyno gave me was to take visanne.
In addition to pelvic pain I find sometimes I have pain (cramping) with sex/orgasm.
Those of you diagnosed with endo what do you think? Does any of this seem similar to your experience?

Finding Effective Alternatives to Opioid Medications for Patients with Acute Pain: A Double-Blinded, Randomized Controlled Trial in the Emergency Room By: XXXXX
ABSTRACT
Every year, millions of American Emergency Room (ER) patients are treated with pain medications - many of them being powerful opioids that may cause harmful side effects and influence long-term addiction. With an aim to find alternatives to opioid usage in hospitals nationwide, this study compares the effectiveness of non-opioid drugs with opioid drugs in treating patients with acute pain in the ER. In this experiment, 349 patients with acute pain at The Brooklyn Hospital Center Emergency Department, with a mean age of 47.4 years, were enrolled. They were randomly selected to receive one of three treatment protocols: Treatment A (non-aspirin medication/s), Treatment B (NSAID medication/s), or Treatment C (opioid medication/s). An emergency rescue protocol served as Treatment D, in the case where a patient suffers any adverse events from the experimental treatment. It was hypothesized that participants given non-opioid treatments (Treatments A and B) would exhibit as much pain relief as participants given opioid treatments (Treatment C) as measured by the 10-point Numeric Rating Scale (NRS). It was also predicted that those given non-opioid treatments would have a tendency to display less adverse effects to the medication and have to resort to the emergency protocol (Treatment D - intravenous morphine). The results showed that participants, on average, did not show a statistically significant difference in pain relief when receiving opioid medication than when receiving non-opioid medication. Adverse events were more prevalent in those who had received opioid treatment than any other treatment group. The hypothesis was confirmed to be true and the results of this experiment are compatible with those in other studies regarding the usage of non-opioid treatments in place of opioid treatments.
Dangers of Opioid Usage and Alternatives: INTRODUCTION
With nearly 130 American deaths everyday, the opioid overdose holds its place as the leading cause of injury-related death in the United States and is responsible for the drug overdose epidemic that has been troubling the nation since the 1990s. The majority of these deaths are a consequence of prescription opioids and illicit opioids. (Wilson, 2018) Every year, millions of American Emergency Room (ER) patients are treated with pain medications - many of them being powerful opioids that may cause harmful side effects and influence long-term addiction. Unfortunately, a dependence on opioids can influence one to overdose on the pain medication or even turn to illicit drugs when a patient’s opioid prescription runs out. Nonetheless, there are various alternatives patients can turn to for pain relief and preventative steps providers can take when prescribing medications to lessen the nation’s opioid overdose crisis. The study of drug addiction and pain analgesic alternatives is essential because such research leads to new scientific discoveries regarding the capabilities and limitations behind treatment alternatives that could one day replace more harmful, traditional treatments.
Opioids, or narcotics, are highly addictive due to their lessened potency with prolonged use (which urges users to take more pills for the same effect) and tendency to cause adverse events (like withdrawal symptoms that make it difficult for users to stop taking them). Nonsteroidal anti-inflammatory drugs (NSAIDSs), although not as addictive as narcotics, have been linked to gastrointestinal and cardiovascular adverse effects, as well as an increased risk of dementia. (Wongrakpanich, 2018) This study seeks to shed light into alternative forms of medication to NSAIDs and opioids that may lead gastrointestinal bleeding or addiction to opioids. This study was a randomized, double-blind, placebo-controlled clinical trial that compared the use of non-opioids, opioids, and NSAIDs to treat moderate to severe acute pain in the Emergency Department (ED) at The Brooklyn Hospital Center (TBHC). This hospital is a community teaching hospital with a level II trauma center ED where over 76,000 patients are treated every year. Given the large number of people that are treated here, it would be advantageous for the hospital providers to consider an alternative approach before prescribing opioids to their patients. Many studies have been done to show that opioid usage can be harmful to the body and mind and that effective alternatives to opioids analgesics may exist, even when applied in cases of acute pain. Such studies include that of Krebs, Gravely, Nugent, Jensen, DeRonne, Goldsmith, Kroenke, Bair, and Noorbaloochi (2018), Hartwell, Selley, Terry, and Tjong (2020), Petrikovets, Shehyn, Sun, Chapman, Mahajan, Pollard, El-Nashar, Hijaz, and Mangel (2019), Hauser, Schubert, Vogelmann, Maier, Fitzcharles, and Tolle (2020), Chang, Kigar, Ho, Cuarenta, Gunderson, Baldo, Bakshi, and Auger (2019), and Sotoodehnia, Farmahini-Farahani, Safaie, Rasooli, and Baratloo (2019).
Particularly interesting were the studies conducted on opioid usage regarding chronic postoperative pain. One study by Erin Krebs, Amy Gravely, Sean Nugent, Agnes Jensen, Beth DeRonne, Elizabeth Goldsmith, Kurt Kroenke, Matthew Bair, and Siamak Noorbaloochi (2018) examines and compares the effects of opioid and non-opioid medications in patients with chronic back pain or knee osteoarthritis pain. This was a double-blind clinical trial that helped researchers observe the pain-related function, pain intensity, and adverse effects of opioid and non-opioid medications through the course of 12 months. Patients presenting with chronic back pain or knee osteoarthritis pain were randomly selected and placed into one of two groups: an opioid medication therapy group (n = 117) or a non-opioid medication therapy group (n = 117). The opioid group were treated with immediate-release morphine, oxycodone, or hydrocodone/acetaminophen; the non-opioid group were treated with acetaminophen (paracetamol) or a nonsteroidal anti-inflammatory drug (NSAID). The participants’ pain-related function and pain intensity were measured using a Brief Pain Inventory [BPI] interference scale and a BPI severity scale, respectively. It was observed that the two groups did not significantly differ on pain-related function throughout the 12 months; however, the pain intensity was significantly more improved in the non-opioid group by the end of the study than in the opioid group. In addition, adverse medication-related symptoms were significantly more prevalent in the opioid group than in the non-opioid group. Their results assume the idea that opioids are not the only effective component in chronic pain management; NSAIDs are just as capable in treating chronic pain. Another study that focused on chronic pain was conducted by Matthew Hartwell, Ryan Selley, Michael Terry, and Vehniah Tjong (2020) and it investigated the necessity of opioid medications to treat post-operative pain in knee arthroscopic surgery. This study was conducted in an attempt to curb opioid dependency in patients with post-operative pain and to determine an optimal number of opioids to prescribe after surgical procedures. Patients undergoing arthroscopic partial meniscectomy were randomly selected and were either given a multimodal pain control with aspirin, acetaminophen, and naproxen and randomized to receive oxycodone (group 1: 48 patients) or they were given an optional prescription to fill (group 2: 47 patients). The patients were contacted in intervals up to 1 month after surgery to evaluate medication side effects and opioid usage. The mean number of tablets were used to measure outcomes; a 50% reduction in medication tablets utilized defined a successful outcome. No significant reduction was observed in the number of tablets utilized, days that opioids were required, or postoperative pain between groups 1 and 2 at any time point. In addition, those who were given the option to fill their prescription (group 2) had significantly fewer unused tablets than the group that was given opioids (group 1). Their results indicated that 37% of the participants did not require any opioids after surgery and that 86% of the patients used less than 8 tablets. The results of this experiment support the idea that a multimodal approach to pain control can significantly lessen the consumption of opioids and consequently, the prevalence of opioid dependency. It would be constructive to investigate the benefits of physical therapy alongside a multimodal approach in treating for postoperative pain. Another study regarding postoperative pain was led by Andrey Petrikovets, David Sheyn, Helen Sun, Graham Chapman, Sangeeta Mahajan, Robert Pollard, Sherif El-Nashar, Adonis Hijaz, and Jeffrey Mangel (2019) and it examined alternative treatments to postoperative pain in patients who have undergone vaginal pelvic reconstructive surgery. Traditionally, the method of pain control used after urogynecological surgery has been centered around administration of opioids and narcotics. However, given the harmful side effects of opioids that have led to the United State’s opioid crisis, researchers are seeking substitutes for conventional pain treatments. Patients undergoing vaginal pelvic reconstructive surgery were randomly selected to receive the standard treatment (n = 33) or the multimodal treatment (n = 30). The standard treatment consisted of as-needed ibuprofen and as-needed acetaminophen/oxycodone; the multimodal treatment consisted of ice packs, around-the-clock oral acetaminophen, and around-the-clock intravenous ketorolac. Both pain regimens included intravenous hydromorphone for breakthrough pain. Patients’ primary postoperative pain was recorded using a visual analog the morning after surgery; patients’ secondary postoperative pain was recorded using a visual analog, Quality of Recovery Questionnaire, satisfaction scores, inpatient narcotic consumption, and outpatient pain medication consumption at other time intervals. It was observed that the median initial visual analog scale pain scores and the numerical median pain after 96 hours were significantly lower in the multimodal treatment group than the standard treatment group. Additionally, patients under multimodal treatment received fewer narcotics (hydromorphone intervention) and used less tablets on average (4.9 ketorolac in multimodal; 4.6 oxycodone/acetaminophen in standard) than patients under standard treatment. While there were no statistically significant differences in Quality of Recovery Questionnaire or satisfaction scores either in the morning after the surgery or at the 96 hour follow up, the pain scores indicated a statistically significant improvement in pain control in the multimodal group than in the standard group. The results of this study correspond with the idea that a multimodal postoperative pain regimen is as effective as the standard postoperative pain regimen in treating patients who have undergone vaginal pelvic reconstruction surgery. If a multimodal model of pain regimen can replace the standard model, then postoperative inpatient narcotic use can be limited to a greater extent and outpatient narcotic use can be eliminated in those undergoing vaginal pelvic reconstructive surgery. More investigation is required to determine whether such results can be replicated in cases outside of vaginal pelvic reconstructive surgery. It would be advantageous to gather more information on the uses of multimodal drug interventions, in comparison to opioid interventions, in patients with acute pain.
Other studies focused on the dangers of opioid usage when used over a long time. This database study by Winfried Hauser, Tino Schubert, Tobias Vogelmann, Christoph Maier, Mary-Ann Fitzcharles, and Thomas Tolle (2020) explores the mortality rate and harmful side effects in patients with long-term opioid therapy when compared with non-opioid analgesics for chronic non-cancer pain. Prior to this study, research regarding mortality rates upon opioid usage was limited to certain populations of people and specific drugs. This experiment, however, included data on a larger number of people and compared all established opioids to various non-opioid analgesic therapy (anticonvulsants, antidepressants, dipyrone, non-steroidal agents). Data on 4,711,668 insured patients were retrieved from 61 German health insurances; all-cause mortality of patients was determined from their death certificates. Patients’ age, gender, comorbidity index, and propensity score were accounted for in participants of both groups: long-term opioid therapy (LTOT) group (n = 3,232) and control-drug therapy group (n = 3,232). The data found 554 patient deaths in the LTOT group, in contrast to the 340 patient deaths in the control group. There was a slightly elevated risk of out-of-hospital death in the LTOT group; LTOT group patients had 288 out-of-hospital deaths (compared to 266 in-hospital deaths) whereas control group patients had 110 out-of-hospital deaths (compared to 230 in-hospital deaths). It was also recognized that the LTOT group had a higher likelihood of heart failure, as well as a greater use of psycholeptics and of antithrombotic and antiplatelet agents. Overall, the group that was treated with opioid analgesics was significantly associated with an increased risk for all-cause mortality than the group that was treated with non-opioid analgesics. Other studies have also called out the use of NSAIDS in pain treatment for their association with potentially serious side effects. It would be beneficial for more research to be done on the safety of alternative treatments to replace traditional, and possibly harmful, analgesics.
Other studies looked into the psychological harms that increased one’s biological likelihood of being dependent on opioids. This study by Liza Chang, Stacey Kigar, Jasmine Ho, Amelia Cuarenta, Haley Gunderson, Brian Baldo, Vaishali Bakshi, and Anthony Auger (2019) delves into the impact early life stress (ETS) has on mental health and and postnatal development, particularly one’s resilience to psychopathologies. They found that many psychiatric disorders, like social anhedonia and drug addiction, include dysfunctional opioid signaling. Additionally, central opioid functioning was observed to differ in biological males and females. In this study, a neonatal predator odor exposure (POE) was used on the amygdala and nucleus accumbens (NAc) of male and female rats to model ELS; opioid receptor gene expression was then examined by collected brain tissue at neonatal and juvenile time points. The results showed that POE downregulated neonatal mu- and kappa-opioid receptor mRNA levels in neonatal females, but upregulated mu- and delta-opioid receptor mRNA levels in juvenile females. Interestingly, POE had no statistically significant effect on NAc opioid receptor mRNA levels in males. There was no alteration in amygdalar opioid gene expression in either rat group. The results of this study suggest that the impact of POE on the opioid system is sex-dependent. Such results are important because they provide evidence for the differential risk or resilience for males and females to develop atypical opioid-regulated behaviors that come from psychiatric disorders such as depression and addiction. The data from this study is applicable in an ED setting as it cautions against the use of opioids to treat pain. Patients who come into the ED for an emergency regularly do not provide psychological history that, according to this research, plays an effect in one’s predisposition to opioid addiction and abuse. More research is needed regarding the effect of ELS on other behaviors and systems through changes in the opioid system. Given that opioid receptor mRNA levels saw changes only in females, it appears that biological sex plays a significant role in how early life stress alters opioid receptor mRNA levels in a developing brain. This raises the question of the efficacy of opioid usage in female patients, compared to male patients with acute pain presenting in the ED. If stressors can alter opioid-related pathways in the brain at neonatal and juvenile time points in rats, how would opioid treatments impact the brain during adulthood in humans? Additionally, it would be interesting to investigate the long term impact opioid usage can have on the brain of patients with chronic pain.
One intriguing study looked into alternative analgesics, outside of NSAIDs and opioids, to manage pain. This double-blind study by Sotoodehnia, Farmahini-Farahani, Safaie, Rasooli, and Baratloo (2019) sought to compare the efficacy of low-dose ketamine with that of ketorolac in regards to pain management in patients with acute renal colic in the emergency department (ED). Ketamine is a schedule III drug that acts as a powerful dissociative anesthetic; the drug comes with symptoms including pain relief, sedation, and memory loss and has even been used to treat depression. Renal colic occurs when a stone is embedded in one's urinary tract and is often accompanied by intense pain due to kidney dysfunction. Patients with acute renal colic were randomly selected to be treated with either low-dose ketamine or ketorolac; they were then administered their treatment intravenously at a dose of 0.6 mg/kg and 30 mg, respectively. Their pain severity was evaluated using the numerical rating scale (NRS) immediately after drug administration and 5, 15, 30, 60, and 120 minutes afterwards. The analysis found no statistically significant difference in the mean NRS scores at the different time intervals (except at the 5 minute interval) between the low-dose ketamine (62 patients) and ketorolac (64 patients) groups. In conclusion, a higher rate of adverse drug reactions were observed in those who received ketamine; however, the low dose ketamine was shown to be as effective as ketorolac in managing pain in patients with renal colin at the ED. This raises the question of the extent to which ketamine can be used to manage pain in regards to different routes of administration. A published systematic review (Ghate et al., 2017) reported a broad variation in the dose and route of low dose ketamine in previous studies ranging from 0.1 to 0.7 mg/kg administered subcutaneously, intravenously, or intramuscularly. The exact dosage and route required to properly treat for pain with ketamine still requires further investigation. More studies are required to assess whether ketamine can be used for pain management in patients with chronic pain. It would also be beneficial to investigate the long-term benefits of ketamine usage in decreasing the severity or occurrence of pain, as well as any other hard-to-obtain drugs that may lawfully be restricted from the public.
A thorough analysis of the research described above suggests that other analgesics are capable of being as effective as opioids and, even lead to less adverse reactions. Research also implies that there may be a gender disparity in the efficacy of opioid treatment. Much of the data, however, focuses on the long-term use of opioids for chronic pain, rather than for shorter-term acute pain. Based on this literature, it was hypothesized that participants given non-opioid treatments would exhibit as much pain relief as participants given opioid treatments, and that those given non-opioid treatments would have a tendency to display less adverse effects to the medication.
METHOD
Participants
The participants (N = 349, 126 males and 223 females) (67% African-Americans, 20% Hispanics, etc) in this study were patients that voluntarily visited the ED at TBHC to treat moderate to severe acute pain. Inclusion criteria for eligibility in this study were English-speaking adults (18+ years old), who entered the ED with a chief complaint of moderate to severe acute (📷days) pain (📷3/10 on NRS), and were willing to provide informed consent. Patients who were enrolled in this study presented with the following areas of pain: abdominal pain, chest pain, neck pain, leg pain, flank pain, knee pain, headache, foot pain, shoulder pain, femur fractures, back pain, ankle pain, body aches, facial pain, thigh pain, trauma, breast pain, buttock pain, toothache, rib pain, finger injury, hand pain, kidney pain, groin pain, RLQ pain, ear pain, musculoskeletal pain, cramps, rectal pain, virus pain, hip pain, and elbow pain. Data on types of pain was categorized by bodily location and function in order to run statistical analyses.
Exclusion criteria included
- allergy to ketamine/morphine/lidocaine/ketorolac(Toradol)/corn/aspirin/ibuprofen
- hemodynamic instability (heart rate not within 60-110 beats/min, blood pressure <90/50 mm Hg or <180/100 mm Hg, respiratory rate not within 12-20 breaths/min, and oxygen saturation <94%)
- unwillingness to provide consent
- history of cardiovascular disorders (myocardial infarction, ischemic heart disease, atrial fibrillation, heart blocks, Wolff-Parkinson-White syndrome, slow heart rate, bradycardia, coronary artery disease, QT prolongation, etc.)
- history of liver dysfunction (cirrosis), chronic alcohol abuse, gastrointestinal bleed or recent gastrointestinal bleed (within 5 days), renal dysfunction or disease, seizures (or currently actively receiving treatment for seizures), inflammatory bowel disease (or currently actively receiving treatment for IBD), hepatitis (or currently actively receiving treatment for hepatitis)
- liver transplant
- on dialysis
- acute heart, kidney, livery, respiratory failure or trauma
- altered mental status or history of schizophrenia, depression, or substance abuse
- traumatic head injury with or without loss of consciousness
- Actively breastfeeding or pregnant
- language barriers where patient is unable to express/describe pain
- weighing at or over 130 kg
- blood pressure >180/120 mmHg at triage
- previously enrolled in study
They were provided analgesic pain medication to treat their acute pain whether or not they consented to participation in this study.
Materials
This study was a randomized, double-blind, placebo-controlled clinical trial that compared the use of opioids, NSAIDs, and other analgesics to treat moderate to severe acute pain in the Emergency Department (ED) at The Brooklyn Hospital Center (TBHC). This hospital is a community teaching hospital with a level II trauma center ED where over 76,000 patients are treated every year. TBHC’s institutional review board has approved the study protocol. Written and verbal informed consent was obtained from all participants in the study in accordance with institutional policy. The non-aspirin medications included in Treatment A include the following: acetaminophen, lidocaine, and bupivacaine. The NSAIDs included in Treatment B include the following: ketorolac, ibuprofen, and aspirin. The opioid analgesics included in Treatment C include the following: morphine, fentanyl, oxycodone, percocet, and codeine. The medication for the emergency protocol used in Treatment D utilizes intravenous morphine. There were also some cases in which low-dose ketamine was utilized as an analgesic.
Procedure
The purpose of our study was to assess the safety and efficacy of non-aspirin, NSAIDs, and anesthetic analgesics as a treatment for acute pain in the ED in relation to opioid medications. This study seeks to shed light into alternative forms of medication to NSAIDs and opioids that may lead gastrointestinal bleeding or addiction to opioids. It was hypothesized that non-aspirin and anesthetic analgesics would be just as effective in decreasing a patient's perception of pain, as measured by the 10-point Numeric Rating Scale (NRS) in comparison to opioids. Our hypothesis was first tested by obtaining a patient-reported pain score in 15 min intervals before and after the initial administration of the treatment intervention: 0 (no pain) and 10 (excruciating pain). Research assistants (RAs) also recorded changes in patient’s pain at the injection site, overall pain score, incidence of nausea, incidence of vomiting, heart rate, systolic/diastolic blood pressure, respiratory rate, O2 saturation, incidence of dizziness, incidence of headache, incidence of arrhythmias, incidence of disorientation, incidence of hives/rashes/itchiness, and incidence of hallucinations). Our hypothesis was assessed further through the incidence of adverse reactions, need for and mean consumption of rescue analgesia, length of stay in the ED, and satisfaction of pain management (10-point Likert scale).
Before the start of the study, four-digit study numbers are randomly generated by the pharmacy investigator through the use of a computer-generated block randomizer. These numbers were placed in individually sealed opaque envelopes that are sequentially numbered and safely placed in the ED Research Office. The study numbers correspond to the different treatment interventions given to patients. Treatment A follows the given protocol: 1.5 mg/kg anesthetic analgesic or non-aspirin by intravenous piggyback (IVPB) in 50 mL normal saline over 10 minutes x 1 dose, followed by 1 mL normal saline by intravenous push injection x 1 dose. Treatment B follows the given protocol: 30 mg (1 mL) ketorolac, ibuprofen, or aspirin intravenous push injection x 1 dose, followed by 50 mL normal saline over 10 minutes x 1 dose. Treatment C follows the given protocol: 0.1 mg/kg (max 10 mg) of morphine, fentanyl, oxycodone, percocet, or codeine by intravenous push x 1 dose, followed by 50 mL normal saline by IVPB over 10 minutes. The dosage of the medication prescription was altered by the attending physician based on the patient’s needs and body. The different treatment interventions were processed and distributed by the central pharmacy and were given to each participant once during the study period. In the case where the treatment intervention leads to an adverse effect, the patient is taken off the treatment and administered morphine 0.1 mg/kg intravenous (IV) push, maximum 10 mg. The morphine is also administered if the patient reports pain score above 4/10 after receiving the study treatment. The morphine is not supplied by the central pharmacy but from the nurse assigned to the patient via the automatic dispense cabinets in the ED.
The ED TBHC patients have been recruited and enrolled into this study in four 4-hour blocks of time (8:00AM - 12:00PM, 12:00 - 4:00PM, 4:00PM - 8:00PM, 8:00PM - 12:00AM). During these blocks of time, 2 trained research assistants (RAs) screen the patients in the ED for study eligibility through the ED’s medical record system. Once the RAs identified possible candidates for the study, they notified the emergency physician (ED attending, resident, physician, or nurse) of the patient’s eligibility into the study. After the ED physician performs a physical examination on the patient, the RAs communicate with the patient for interest and consent in participating in the study. If the patient expressed interest and provided consent, the RAs use a customized screening form to further determine the patient's inclusion into the study. Once a patient is believed to be eligible for the study, the RAs and a study investigator enroll the patient into the study. The patients are given a 4-digit study number (0000 - 9999) by the RAs once they are enrolled into the study and a medication order for the study treatment intervention is placed in the electronic medical record by the patient’s emergency physician. The physician will have placed the study number under “additional comments” for the order and after the order is verified, it will be prepared by the central pharmacy. After the study intervention is prepared, it was sent to the patient’s assigned nurse by the RA. As this is a double-blind study, the only individuals with knowledge of the treatment intervention’s identity are the pharmacists in charge of preparing and dispensing the drug, the study investigator, and statisticians. The nurse administers the treatment to the participant and RAs are in charge of collecting data regarding participant’s progress and developments. Data collection ends 120 minutes after administration of treatment or upon patient discharge -- whichever comes first.
Results
It was hypothesized that participants given non-aspirin, NSAID, or anesthetic analgesic treatments would perceive as much pain relief as participants given opioid treatments, and that those given opioid treatments would have a tendency to display greater adverse effects to the medication. The results showed that participants, on average, did not show a statistically significant difference in perceived pain between the three treatment protocols. [summarize data here - separate non-aspirins, anesthetics, NSAIDs, and opioids] [tendency for adverse events to occur] [cases of multimodal treatment - as proposed by attending physician] [sex-differences in percieved pain across treatment protocols] [differing body parts and perceived pain based on different treatments] [was there a difference in medications across its type? Ex. morphine vs. oxy] The hypothesis was confirmed to be true and the results of this experiment are compatible with those in other studies regarding the usage of non-opioid treatments in place of opioid treatments.
Tables/Figures
[PRISMA flow diagram of patients and their groups] [Subgroup analyses - people of same pain type receiving different medications - opioid v. nonopioid / NSAID v. nonNSAID]
[Subgroup analyses - sex differences in pain perception]
[Subgroup analyses - difference in perceived pain in medication across med group] - unnecessary?
[group analyses - average changes in perceived pain between drug groups]
[group analyses - people who received 1 medication vs. people who required more]
[group analyses - which treatment group left the ER the quickest? Incomplete data] - unnecessary?
[group analyses - does the route in which a specific medication is taken, make a significant difference]
Discussion
As hypothesized, participants given non-aspirin, NSAID, or anesthetic analgesic treatments perceived, on average, the same pain relief as participants given opioid treatments. The results showed that the average difference in perceived pain scores (based on the 10-point Likert NRS) between opioid and non-opioid groups to be statistically insignificant. There was also a greater likelihood of those in opioid groups to experience adverse events during treatment. [observations in people of same pain type receiving different medications] [sex differences in pain perception] [average changes in perceived pain between drug groups] [those who received multimodal treatment bc the given treatment was not enough]. [Did those who received non-opioids end up having to take a larger dosage?] Therefore, participants on average had a [SUMMARIZE the results].
These results are compatible and consistent with the results achieved in the experiments conducted by Krebs, Gravely, Nugent, Jensen, DeRonne, Goldsmith, Kroenke, Bair, and Noorbaloochi (2018), Hartwell, Selley, Terry, and Tjong (2020), Petrikovets, Shehyn, Sun, Chapman, Mahajan, Pollard, El-Nashar, Hijaz, and Mangel (2019), Chang, Kigar, Ho, Cuarenta, Gunderson, Baldo, Bakshi, and Auger (2019) [ONLY include this one if there was a sex-dependent difference], and Sotoodehnia, Farmahini-Farahani, Safaie, Rasooli, and Baratloo (2019) [ONLY include this one if there was a significance in the ketamine usage - check if theres enough sample for this to be valid]. As was predicted, there are alternative analgesics that can be as effective as, and safer than, opioids in managing patients’ pain in the ED. This was expected based on research concerning opioid usage to treat physical pain and on data from previous studies regarding the adverse effects behind opioid usage. This was seen in the study by Krebs, Gravely, Nugent, Jensen, DeRonne, Goldsmith, Kroenke, Bair, and Noorbaloochi (2018) that showed that patients who received opioid treatments, when compared to those who received non-opioid (NSAIDs) treatments, did not significantly differ on pain-related functioning throughout the 12 months (based on a BPI interference and severity scale). Similar to our own experiment, they also found adverse medication-related symptoms to be significantly more prevalent in the opioid treatment group than in the non-opioid treatment group. In addition, those who had received non-opioids had quicker functional pain-relief than those who had received opioids [ONLY include this if my data suggests non-opioid patients left the ER significantly quicker than opioid patients]. Another study that had similar results was the one conducted by Hartwell, Selley, Terry, and Tjong (2020) to investigate the necessity of opioid medications in treating post-operative knee arthroscopic surgery pain. They found that patients who used opioids as-needed used significantly less tablets than those who were prescribed opioids. Corresponding to our own data, it was observed that those who had received multimodal treatment experienced less pain over time and had lessened dependency for opioids than those who had received opioid treatment. Another study whose results correlate with our data includes that of Petrikovets, Shehyn, Sun, Chapman, Mahajan, Pollard, El-Nashar, Hijaz, and Mangel (2019). Much like the previous study, these researchers examined the efficacy of alternative methods, in place of opioids, to alleviate postoperative pain. Their results suggest a multimodal treatment regimen is as effective in managing pain than the standard opioid treatment regimen. It was also noted that those who underwent a multimodal regimen had a tendency to use less opioids and, as a result, had a lower likelihood of dependence. These results corroborate with our study because our results showed that non-opioids contributed to as much pain relief as opioids did, even when paired with other analgesics. All studies’ data also agreed that opioid usage often correlates with the experience of adverse effects. Chang, Kigar, Ho, Cuarenta, Gunderson, Baldo, Bakshi, and Auger (2019) [ONLY include this one if there was a sex-dependent difference], and Sotoodehnia, Farmahini-Farahani, Safaie, Rasooli, and Baratloo (2019) [ONLY include this one if there was a significance in the ketamine usage - check if theres enough sample for this to be valid - THIS ONE would be interesting to add info to tho bc it has to do w ACUTE PAIN]
While our results were corroborated by many studies and successfully proved our hypothesis, there are certain limitations that still existed. One such is that the participants were not presented with the same people when taking part in the study. Because our results depended on the patient’s perception of pain, the self-reported pain scores may have been skewed based on the patient’s opinion of the attending physician, nurse, and RAs working with that patient. The fact that patients grew accustomed to those working with him or her further exacerbates this problem. [include research on habituation and pain perception if possible] This is something that can be accounted for in future studies. Another factor that was not accounted for was comorbidities and psychological background history that may have played a role in a patient’s physiological reaction to the treatment. This was a factor that was taken into account in the study by Häuser, Schubert, Vogelmann, Maier, Fitzcharles, and Tolle (2020) and Chang, Kigar, Ho, Cuarenta, Gunderson, Baldo, Bakshi, and Auger (2019). The 2020 investigation recognized this as an important factor as they found that comorbidity rates correlated with mortality rates in those who had undergone long-term non-cancer pain treatment. The 2019 study identified brain regions relevant to opioid usage that were altered through psychological stress. By failing to note such details, our data became subject to confounding variables that may have led to skewed results. In addition, the location and status of the hospital may have contributed to sample bias; a vast majority of minorities (67% African-Americans and 20% Hispanics) made up our sample, indicating that the results may not be representative of a more variable population. [include research on the reason behind the population and people of what socioeconomic or racial backgrounds are usually part of what hospital] Our results were also limited due to the short time-span we are with the patient; once a patient leaves the ER, it is difficult to hear back from them. It is difficult to collect data if the patient were to experience any long-term adverse events as a result of short-term care, outside of the ER. In the future, we should extend the implications of this study on opioids, NSAIDs, anesthetics, and non-aspirin analgesics, specifically in regards to greater sample diversity, more patient background, more uniform RA training, and patient contact after the first encounter.
Mention other alternatives to opioids that may be useful to eliminating the opioid epidemic in the US. prescription and over the counter drugs (aspirin, ibuprofen, acetaminophen, steroids), massages + acupuncture, radio waves + electrical signals, physical therapy, surgery, injections or nerve blocks, spinal cord stimulation, pain pumps, stem cell research (still in progress), CBD, marijuana, ketamine? - (AS 2019) While opioids are very effective in alleviating the perception of pain, their harmful long-term side effects and prevalence of addiction contribute sjdhbfcas

Back in 2012 I went through the typical routine with a herniated disc in my lower back giving me extreme pain (physical therapy, injections, pain management, and eventually surgery as I was showing some weakness in my foot)
I got the surgery and I was virtually pin free until this past summer.
I got a new exercise bike (peloton) and hit it hard for a month and end up having some lower back pain since it wasn’t dialed in quite right (I also assume this is the cause but don’t know for sure)
I went from a sore back, to a sore hip to the dreadful feeling of nerve pain going down my right leg. It progressed for a couple of weeks until this past Friday when it started to get unbearable and my routine of ibuprofen was not helping it stay in line.
Thursday Pain management, they did a quick examination and gave me some options Diclofenac and a muscle relaxer with an injection next Friday.
Friday I started the meds from pain management and this evening I started down the path of some intense pain and went to the urgent care to see if they could offer any relief. Got some low dose Tylenol with codeine and some prednisone which was enough to get me to sleep.
Saturday Morning I woke up and could barely function and get out of bed so off to the ER we go since it seems to be getting worse. They check me out refer me to a neurosurgeon and suggest the typical routine but send me home with some new pain meds.
Saturday Evening Nothing is working I can barely stand and going to the bathroom is virtually impossible to sit or stand. I of course am getting concerned there is no way I can function. I can’t sit, I can’t stand, and I barely can lay in one spot.
Off to the ER we go again. This time they see things have progressed further and do a full work up with blood and MRI. During this visit they give me some morphine and also toradol. Finally some relief even though it will be temporary.
MRI reveals a moderate disc herniation around L4 and L5. They go over the information and recommend dosage of ibuprofen, Tylenol, and some muscle relaxers and I am sent home feeling pretty good since the morphine and toradol is still in my system.
Sunday I wake up with almost no pain, some mild tingles but I can walk around slowly and somewhat function as normal. This feels great! I take it easy and keep up a strict schedule of meds and watch Netflix. Fearing the worst I go to bed. I slept to with a heating pad and legs propped up with a pillow.
Monday I wake up and again feel pretty darn good, keep up the meds and do a few odd errands to try to get a bit of light walking in. A few tingles but overall things are going good.
Tuesday I wake up and low and behold things still feel ok. Nowhere near 100% but super nervous of it coming back so I have been very easy going, bit of walking no twisting, turning or bending and taking it very slow.
Later this week I also am meeting with a back specialist tomorrow to get his perspective on my series of events and to see if there is any reason to go forward with the injection on Friday if the pain as subsided (it feels like i shouldn’t since why potentially mess up a good thing?)
I went from intense pain to almost no pain simply overnight after my last ER visit.
Does anyone have any idea how this happened or if this is just short lived? ( My only thought is Torodal and morphine let me relax my tensed and inflamed muscle?)
Edit 2019-10-16 Talked to the pain management clinic and since the pain has subsided there is no logical reason to do an injection. Had an appointment with a Urgant care orthopedic back specialist and after going over the past couple days mentions that all the anti inflammatory medications is most likely the cause of my sudden feeling of better. I was able to reach down and touch my toes which was quite shocking given how I felt the past weekend. I am lined up with some physical therapy and hopefully with this change of events I can let this heal via conservative means. The Dr did mention after looking at my MRI did see it is a re herniation of my previous disc and if it does come to surgery recommends a fusion (not a fan of that at all)

G'day all.
I don't really know what the point of this post is, I guess I'm looking for advice or anything really. This is kinda gonna be all over place, so bare with me.
I have been suffering from frequent to daily migraines since I was about 10 years old. They started getting really bad when I was about 18, I'm currently 22.
I currently take 12.5mg of Amitriptyline, and 200mg of 5-HTP plus as a preventative, 3hrs before bed.
Sometimes it works, mostly it does not, but I'm pressing on, I was on Ami for a month or so before I had to stop taking it due to ineffectiveness, and the serious drowsiness. I have now been back on it for almost a month.
I also take 5 Tylenol #1s twice a day, which has been most effective, and works 99% of the time. The 1% time it doesn't work, I take 5-10mg of maxalt and 440mg of naproxen. Toradol causes horrid rebounds, regular ibuprofen and tylenol does jack all.
I have tried beta blockers, calcium channel blockers, neither work. I don't have the ability to take ergots, for insurance reasons, and every doctor I've seen refused to prescribe any regardless.
I've tried nabilone and just straight up marijuana, to no avail. The only thing that seems to work is codeine. Codeine and triptans. No matter how hard or how badly I don't want to take narcotics, I really don't have a choice... It's getting to the point where I would almost rather be addicted to opiates than suffer in pain, because that seems to be the only thing that works. And when it doesn't I jump to Aleeve and Maxalt for temporary relief until the T1s start working again. Its like they are the preventatives because I rarely get a migraine or headache when I take them. I could easily go through 300 t1s in a month. And thankfully I live in Canada so they pretty much hand them out like candy here.
Aside from my concerns of addiction (in which I'm already dependent, same as the amitriptyline), I'm also concerned about my liver function. As I said, I take 5 Tylenol 1s as a dose, twice a day. That can be anywhere from 3000 - 3250mg of acetaminophen a day, for years.
If I take triptans regularly, I get horrible rebounds, if I take toradol it makes my migraine worse, I've tried stopping all meds for a period of 3 months which was the worst three months of my life. I've tried eating heathy, eating badly, being lazy, being active, I've quit smoking, lay off the caffeine, I've tried various supplements and preventatives.
I just can't live in pain, and I'd prefer to not live taking narcotics and killing my liver. But at least narcotics make me able to function properly.
I am under a lot of stress, none of which can be controlled or eliminated, and could be a very likely cause of the frequency and severity of migraines - I have a severely medically ill and complex 3 year old.
I really don't know what to do, why to do, or how to do, or what even this is. I've gotten various scans done and all that fun stuff. My mother and grandmother and so on have suffered the same way until they hit menopause, however I'm male.
I know this is kinda all over the place but I don't really know where I should start or what even to say... I've probably forgotten some info, but fuck it. I've tried everything, nothing works, or just has generally not with it side effects.
Tl:dr: fuck