Hospital system offers laughing gas as an opioid alternative
ProMedica Toledo and Flower Hospitals recently announced their plan to implement nitrous oxide as a pain reliever in their emergency departments to curb the effects of the opioid epidemic.
Dr. Brian Kaminski, ProMedica’s vice president of quality and patient safety, is heading the Prescribing Alternatives Instead of Narcotics (PAIN) project, a grant-funded program to reduce opioid use in hospitals. Kaminski said that nitrous oxide is a quick, safe, and easy alternative to opiates or stronger sedatives that can be used in many emergency room situations.
“It’s very brief, it’s very safe, and it’s easy to administer and well-tolerated by patients,” he said. “So it eliminates some of the side effects we see with moderate or deep sedation, those higher levels of sedation. It’s a good drug to use in the space between doing nothing or giving an opiate or full-on anesthesia.”
Nitrous oxide, nicknamed “laughing gas,” is a colorless, odorless gas absorbed by inhalation. It’s a mild analgesic, meaning its light pain-relieving properties help patients disassociate from pain and relieve their anxiety.
According to a ProMedica news release, nitrous oxide has been proven an effective treatment for both migraines and musculoskeletal injuries, which are among the top-presenting pain complaints seen in Toledo and Flower Hospitals’ emergency departments.
Kaminski said nitrous oxide is a valuable resource for any temporary painful or anxiety-inducing condition, including joint dislocations, repairing lacerations, draining abscesses, inserting IVs, spinal taps, and more.
There are a few contraindications with nitrous oxide – doctors can’t use it on people who are already intoxicated, children less than 1 year old, people with vitamin B12 deficiency, or people with impaired oxygenation. Other than that, Kaminski said, it’s fair game.
The drug isn’t new – it’s been used for decades in dental practice to relieve pain and anxiety around dental procedures. Nitrous oxide also used to be used more frequently in hospitals and emergency departments, but once opiates entered the scene, laughing gas lost popularity.
It takes more training, equipment, and time to use nitrous oxide, which made opiates look like the easier path to take. But medical professionals didn’t know at the time how addictive opioids could be.
“Over the course of the last few decades, we believe that the use of opiate pain medicines has gotten to a point where it’s contributed to the opioid epidemic,” Kaminski said.
According to data from the National Institute on Drug Abuse, opioid pain relievers are the most frequently prescribed medication in the country. In 2020, the United States rate for opioid prescriptions was just over 43 scripts per 100 people – the lowest rate in 15 years, but still a total of more than 140 million prescriptions.
Ohio’s rate is higher. Its rate was 47.4 opioid prescriptions per 100 people in 2020. In 2018, Ohio had the fourth-highest rate of opioid-involved overdose deaths in the country, with almost 30 deaths per 100,000 people.
Additionally, the institute found that between 21%-29% of patients prescribed opioids for chronic pain ended up misusing them, and one in 10 developed an opioid use disorder.
“Now that we have lived through the opioid epidemic and we realize the negative effects of it, and we recognize the importance of not just initiating opiates on anybody, we’re literally blowing the cobwebs off of [nitrous oxide] and realizing hey, this is a really good option, and we should bring it back and use it,” Kaminski said.
ProMedica expects the PAIN program to serve 8,000 individuals over the next three years. Though the grant money went to ProMedica Toledo Hospital and ProMedica Flower Hospital, many ProMedica doctors travel amongst the group’s many hospitals statewide, and will bring their nitrous oxide certifications with them.
Despite Kaminski’s high praise of the program, Mahjida Steffin, the supervisor of overdose prevention and harm reduction at the Lucas County Opiate Coalition, is hesitant about the switch to nitrous oxide — unsure if it could directly lead to fewer overdose deaths.
“It’s very hard to say,” Steffin said. “I think that a lot of people who do have chronic pain probably get a little nervous when it comes to pain management and what new changes will bring, so I’m really hoping that people who are using opioids appropriately and not misusing them don’t have to suffer due to switching this up.”
However, Steffin noted that she has seen ProMedica make great strides in its safe prescribing and prevention efforts.
“Ultimately I’m curious to see if it will have an effect,” Steffin said. “I think there’s all these new things coming down the pike that we’re just kind of like, trial and error trying to figure out, so hopefully this is something that could potentially make a dent.”
Another part of ProMedica’s efforts to shift its approach to pain management is non-pharmacological pain reduction interventions like the Securing Access for Emergency BBB Recovery (SAFER) program. The program works to identify patients with opioid use disorders, initiate treatment, and transition them to longterm care, all as soon as they enter the emergency room.