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I have a few quibbles about your conclusion and overall tone towards this paper. First of all, I don't think our goal is to obliterate all pain, but to try and lessen it and make it more bearable. Maybe ED prescribing isn't the main source of the opioid crisis (which you covered in abstract 4 - I blame the surgeons and the pill farms), but if there are safe, less addictive, and relatively effective alternatives, then it seems reasonable to use those. I have colleagues who use lidocaine quite often and report good patient pain control (anecdote, I know).
I think the main problem with this paper is that it's comparing anything at all with DILAUDID, which everyone LOVES. We've all heard the old chestnut that goes something like "Um, yes Doctor, I'm allergic to all those pain medicines except the one that begins with a D ..." or "Nothing works for me except Dilaudid." There's a reason for that. I've never had it, but acquaintances and co-workers who have say it makes you feel awesome, even compared to previous doses of morphine or fentanyl which they'd received.
I try to stay away from using it in general and go more to morphine and/or fentanyl if I need an opioid. I think a more fair set of questions, and more fair commentary on your part, would be to evaluate/discuss how well lidocaine works in general - what are patients' pain scores (fraught as pain scores are, I know) before and after lidocaine was given? How does it compare to standard doses of morphine and/or fentanyl? And as something of a control, how do morphine and fentanyl compare to Dilaudid? I have a very strong suspicion that if you compared a standard dose of morphine to 1-2mg of IV Dilaudid, you'd probably get somewhat similar outcomes as lidocaine v. Dilaudid BECAUSE EVERYONE LOVES DILAUDID!!
PS - I really appreciate the work you do and generally agree with your conclusions. Thanks.
Sorry to keep going on, but I just listened to the 400mg v. 600mg v. 800mg ibuprofen ED doses and you were WAY more nuanced, probing, and nitpicking in your analysis than with this article, which makes it all the more surprising how readily you simply accepted the results.
What you do matters.