The other 25 percent eventually needed opioids to curb pain, most of them patients with sciatica, kidney stones or migraines so devastating that they resisted a non-opioid headache protocol developed by the Cleveland Clinic. Upon discharge, some of them were given a limited prescription for opioids. E.R. staff not only warns these patients about the medications’ risks, but, to help prevent acute pain from becoming chronic, connects them with hospital physical therapists, pain management specialists, psychiatrists and primary care physicians who have committed to sticking to the program’s goals.

The E.R. staff is beginning to embrace the non-opioid options. “I’m thrilled,” said Allison Walker, a nurse. “I’d hate to be the first to give Percocet to a teenager who dislocated his knee at hockey practice. And then he comes back a year later, addicted to opioids? I don’t want that on my conscience.”

One patient in the pediatric E.R. recently was a 17-year-old high school varsity baseball player, who had been treated with intravenous opioids at another E.R. for a lower-back compression fracture. Physicians sent him home with tapentadol, a strong opioid.

Throughout the week, the teenager was roiled by side effects, including constipation and panic attacks. His pain did not abate. An orthopedist sent him to St. Joe’s, where he arrived sleep-deprived, thrashing and incoherent.

St. Joe’s pediatricians used a non-opioid protocol including a nasal spray of ketamine, a powerful drug which, in low doses, has analgesic and sedative properties. Within 30 minutes the patient was smiling, quiet and, without flinching, able to be transferred to a gurney for scans.