Opioid Alternative Analgesics in the ER

William Kelly, MSN, FNP-C

Updated June 2026 · Medically reviewed for nurses

9 min read

Opioids are necessary in medicine — they provide essential pain relief for those experiencing both acute and chronic pain. From kidney stones to chronic back pain, opioids are often necessary to improve quality of life for those suffering from debilitating pain.

However, opioid alternative analgesics should not be ignored. There are often valid reasons to start with these non-opioid analgesics first, or to use them as adjuncts to minimize side effects and provide better overall relief.

Why Even Consider Opioid Alternatives?

It's no surprise to anyone in healthcare that some patients are classified as "drug seekers," lying to providers so they can continue to score narcotics. Regardless, nurses and providers should still provide pain relief as best they can, without bias or judgment. We can only do our best to relieve pain while staying cognizant of the potential for abuse. But healthcare workers should consider opioid alternatives in far more patients than just potential "drug-seekers."

Opioids provide great pain relief but also come with quite a few side effects. These include nausea and vomiting, sedation, respiratory depression, and even hypotension.

Ofirmev (IV Tylenol)

Ofirmev, or acetaminophen, is your standard Tylenol but in IV form. Tylenol is one of the safest pain medications you can take — as long as you don't overdose (trust me, Tylenol overdoses are NOT pretty). While Tylenol pills work decently, IV Tylenol anecdotally seems to work great for some people, and the IV route ensures rapid action and onset of pain control.

However, studies are mixed on whether IV Tylenol provides superior pain control to PO Tylenol; a systematic review suggests no clear indication for prescribing IV over PO — at least when the patient can tolerate oral. But even oral Tylenol is a valid opioid alternative and has been shown effective for many types of pain, especially as an adjunct.

Ketorolac (IV/IM Toradol)

Ketorolac (Toradol) is a staple in the emergency department. We often give it when we suspect musculoskeletal causes of pain, when the patient has an orthopedic injury or surgery, or for renal colic. It can be given IM or IV.

Ketorolac (Toradol)NSAID — "IV ibuprofen"

Common dosages are 60 mg IM and 15–30 mg IV. As an NSAID, those allergic to NSAIDs or with GI bleeds or significant cardiac disease should probably get something else. A common misunderstanding is that IV Toradol is safe for upper GI bleeds or gastritis because it's IV — but the action of Toradol still inhibits prostaglandin synthesis and can lead to stomach irritation and decreased renal perfusion. When used at appropriate doses, side effects from a one-time dose are rare (dizziness, nausea, or headaches).

Interestingly, IM Toradol hasn't been shown to be more effective for pain control than PO ibuprofen in ER patients [6]. The IV route does offer a more rapid onset. Traditionally 30 mg was used for IV dosing, but a randomized control trial indicates that IV doses at 10, 15, and 30 mg all offered similar pain relief. Many providers order 15 mg IV, especially for geriatric patients.

Lidocaine

Similar to Toradol, lidocaine can be useful for both musculoskeletal and renal colic pain — just in different forms.

Lidocaine topical patches are often used for musculoskeletal pain from a muscle strain or chronic back pain. A Cochrane meta-analysis indicated "some indication that topical lidocaine offered benefit," specifically for neuropathic pain, though the trials were poor. It is often used because of its high safety profile and limited adverse reactions from minimal systemic absorption.

5% lidocaine patches should be placed on the most painful area and left for 12 hours; up to 3 patches can be used at once for a large area. Brand Lidoderm patches can be expensive (~$24 per patch — a 30 count is > $600 without insurance). A cheaper option is 4% lidocaine cream, about $30 for a month's supply.

IV lidocaine has traditionally been used as an antiarrhythmic for dangerous ventricular arrhythmias like VTACH or VFIB. However, IV lidocaine has also been shown to offer significant pain relief for various types of pain including neuropathic pain and renal colic [7],[2]. The normal dose is 1.5 mg/kg (max 200 mg) over 10 min. Cardiac monitoring should be applied during and for 30–60 minutes after the infusion. If given, it should probably be combined with IV Toradol for adjuvant therapy if tolerated.

Flexeril (Cyclobenzaprine)

Cyclobenzaprine (Flexeril) is another opioid alternative for musculoskeletal pain, specifically involving the muscles. For any type of muscle strain, Flexeril can help relax the muscles and offer some pain relief. It is usually not used alone but in conjunction with Tylenol or an NSAID like ibuprofen/naproxen, and is best as a short-term treatment for muscle strains or back pain.

Other Opioid Alternatives

There are multiple other specific treatments for pain depending on the source.

Reglan

Works directly on migraine pain.

Pyridium

Relieves bladder pain from UTIs.

Low-Dose Ketamine

Can be used for chronic and perioperative pain.

Non-Pharmacologic

Heat or cryotherapy, massage, acupuncture, even guided imagery (rarely a valid option in the hospital).

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