Pain Management in the July 2006ottawaemahd.weebly.com/uploads/2/1/7/2/21729574/pain... · 2018. 9....

Pain Management in theEmergency DepartmentA twenty-seven-year-old man presents to the emergency department after a motorvehicle crash. The paramedics relate that the mechanism was a rear end collisionat approximately 20 mph. The patient was the restrained front-seat passenger, noairbags deployed, and there was only minor damage to the vehicle. The patientstates he struck his knees against the dashboard and he is complaining of kneepain, chest pain, and abdominal pain where he was restrained by the belt. Hisexam is unremarkable; his x-rays, ultrasound, and CT scans are all negative. Hishematocrit remains stable throughout his observation.

However, complicating the encounter is the fact that the patient has sickle celldisease and has been to the department many times in the past for pain crises. Hishematologist follows him closely and he is not known to go to any other ED in thecity. During his time in the ED, he initially receives 2 mg of morphine intra-venously, followed by a repeat dose of 4 mg; afterwhich, his requests for more painmedication are denied and he is told that he has already received more pain medi-cine than would typically be given for this mechanism of injury. When the patientis discharged from the department he is instructed to use his regular pain medica-tion (which he claimed he was out of) and no new prescription was provided. Thenext week, the department’s Medical Director receives a letter of complaint fromboth the patient and his hematologist; you are asked to provide a response explain-ing your (lack of!) pain management strategy . . .

There is much in poetry and prose to commend pain. Athletesremember it as the gateway to prowess. Lovers cling to it as a

hope or a memory. And musicians use it as their inspiration. Thisis all well and good, but is not reflective of life in the emergencydepartment (ED). In the ED, pain is almost ubiquitous. It presents

July 2006Volume 8, Number 7

Authors

Liesl A. Curtis, MD, FACEPAssistant Clinical Professor, Department ofEmergency Medicine, Georgetown UniversityHospital—Washington, DC.

Todd D. Morrell, MDClinical Instructor, Department of EmergencyMedicine, Georgetown University School ofMedicine, Washington D.C.

Peer Reviewers

Steven A. Godwin, MD, FACEPAssistant Professor, Director of Medical Education,Department of Emergency Medicine, University ofFlorida HSC-Jacksonville, Jacksonville, Florida

Knox H. Todd, MD, MPHProfessor, Department of Emergency Medicine,Albert Einstein College of Medicine; Director, Painand Emergency Medicine Institute, Beth IsraelMedical Center, New York, NY.

CME ObjectivesUpon completion of this article, you should be able to: 1. Recognize the importance of effective manage-

ment of pain in the ED.2. Understand the available tools at our disposal for

the assessment of pain.3. Understand the pathophysiology of pain and how

it can help guide therapy.4. Recognize that there are special populations with

regard to pain management that may require adifferent approach.

5. Recognize that this is an area in need of improve-ment.

6. Utilize the concepts to design strategies forimproving pain management at your institution.

Date of original release: July 31, 2006.Date of most recent review: July 30, 2006.

See “Physician CME Information” on back page.

Editor-in-ChiefAndy Jagoda, MD, FACEP, Vice-Chair

of Academic Affairs, Department ofEmergency Medicine; ResidencyProgram Director; Director, InternationalStudies Program, Mount Sinai Schoolof Medicine, New York, NY.

Associate EditorJohn M Howell, MD, FACEP, Clinical

Professor of Emergency Medicine,George Washington University,Washington, DC; Director of AcademicAffairs, Best Practices, Inc, InovaFairfax Hospital, Falls Church, VA.

Editorial BoardWilliam J Brady, MD, Associate

Professor and Vice Chair, Departmentof EM, University of Virginia,Charlottesville, VA.

Peter DeBlieux, MD, LSUHSC Professor of Clinical Medicine; LSU

Health Science Center, New Orleans,LA.

Wyatt W Decker, MD, Chair and Associate Professor of EM, MayoClinic College of Medicine, Rochester,MN.

Francis M Fesmire, MD, FACEP, Director, Heart-Stroke Center,Erlanger Medical Center; AssistantProfessor, UT College of Medicine,Chattanooga, TN.

Michael J Gerardi, MD, FAAP, FACEP, Director, Pediatric EM, Children’sMedical Center, Atlantic HealthSystem; Department of EM,Morristown Memorial Hospital, NJ.

Michael A Gibbs, MD, FACEP, Chief, Department of EM, Maine MedicalCenter, Portland, ME.

Steven A Godwin, MD, FACEP, Assistant Professor and EMResidency Director, University ofFlorida HSC/Jacksonville, FL.

Gregory L Henry, MD, FACEP, CEO,

Medical Practice Risk Assessment,Inc; Clinical Professor of EM,University of Michigan, Ann Arbor.

Keith A Marill, MD, Instructor, Department of EM, MassachusettsGeneral Hospital, Harvard MedicalSchool, Boston, MA.

Charles V Pollack, Jr, MA, MD, FACEP,Chairman, Department of EM,Pennsylvania Hospital, University ofPennsylvania Health System,Philadelphia, PA.

Michael S Radeos, MD, MPH, Assistant Professor of EmergencyMedicine, Lincoln Health Center,Bronx, NY.

Robert L Rogers, MD, FAAEM, Assistant Professor and ResidencyDirector, Combined EM/IM Program,University of Maryland, Baltimore,MD.

Alfred Sacchetti, MD, FACEP, Assistant Clinical Professor,Department of EM, Thomas Jefferson

University, Philadelphia, PA.

Corey M Slovis, MD, FACP, FACEP,Professor and Chair, Department ofEM, Vanderbilt University MedicalCenter, Nashville, TN.

Jenny Walker, MD, MPH, MSW, Assistant Professor; Division Chief,Family Medicine, Department ofCommunity and Preventive Medicine,Mount Sinai Medical Center, NewYork, NY.

Ron M Walls, MD, Chairman, Department of Emergency Medicine,Brigham & Women’s Hospital;Associate Professor of Medicine(Emergency), Harvard MedicalSchool, Boston, MA.

Research EditorsNicholas Genes, MD, Mount Sinai

Emergency Medicine Residency.

Beth Wicklund, MD, Regions Hospital Emergency Medicine Residency,EMRA Representative.

International EditorsValerio Gai, MD, Senior Editor,

Professor and Chair, Department ofEmergency Medicine, University ofTurin, Italy.

Peter Cameron, MD, Chair, Emergency Medicine, Monash University; AlfredHospital, Melbourne, Australia.

Amin Antoine Kazzi, MD, FAAEM, Associate Professor and Vice Chair,Department of Emergency Medicine,University of California, Irvine;American University, Beirut, Lebanon.

Hugo Peralta, MD, Chair of Emergency Services, Hospital Italiano, BuenosAires, Argentina.

Maarten Simons, MD, PhD,Emergency Medicine ResidencyDirector, OLVG Hospital, Amsterdam,The Netherlands.

acutely or chronically and accompanies almost everydisease. It strikes anyone from infancy to elderly.While the poets may embrace it and wax eloquently,real people flee from it… to the ED.

While the ED may be the haven for those inpain, effective pain management strategies are oftennot implemented as part of the ED visit. Indeed,emergency physicians, as well as most other special-ists, do not have an admirable record when it comesto managing pain – it is frequently an afterthought,overlooked, or encumbered by fears of creatingaddiction or supporting drug seeking behaviors. 1-3

The truth is, the vast majority of ED patients arenot “drug-seekers,” but seekers of pain relief. Failingto properly address and control pain can detract froma successful resuscitation, stabilization, or diagnosticintervention. Though not necessarily predictable ofpatient satisfaction, it can definitely promote satisfac-tion with the overall ED experience.4, 5 This issue ofEmergency Medicine PRACTICE reviews the state ofpain control in the ED, its complexities, therapeuticoptions, and current controversies.

Critical Appraisal Of The Literature

An extensive literature search through the NationalLibrary of Medicine’s Pub Med database (limited toEnglish language) and a review of the pertinent ref-erences was performed. The National GuidelineClearinghouse (initiative of Agency for HealthcareResearch and Quality and U.S. Department of Healthand Human Services) was reviewed to find the mostrecent guidelines on pain management. The Libraryof Congress’, THOMAS (database of congressionalbills and resolutions), was reviewed to find currentlegislative initiatives related to pain management. Inaddition, the American College of EmergencyPhysicians (ACEP) Clinical Policies were reviewedfor recommendations and guidelines pertaining tothis topic.

Table 1 details some available resources for poli-cies and guidelines pertaining to pain management.In addition to the ones listed, there are treatments forspecific entities (i.e. rizatriptan for acute migraine).The National Guideline Clearinghouse has 107guidelines using key words ‘pain management’and ‘emergency medicine’ that cover a range ofentities, from ankle sprain to chest pain to burnmanagement.

Definitions: Oligoanalgesia

The term “oligoanalgesia” has been coined to describethe phenomenon of undertreatment of pain, and mayresult from multiple factors (Table 2).6, 7

One of the first studies reporting oligoanalgesiain the ED was a retrospective chart review by Wilsonand Pendleton in 1989. 1 They reviewed 198 patientsadmitted to the hospital with 3 categories of pain;intra-abdominal, musculoskeletal and intrathoracic.All of the charts documented that patients had pain,but only 67% of charts had documentation regardingthe degree of pain each patient was experiencing.Overall, 44% of patients received narcotic medicationwhile in the ED, 60% received intramuscular (IM)doses. One-third of patients with documentedsevere or moderately severe pain received sub-opti-mal dosing of opioids; 69% of patients waited morethan one hour for pain medication and 42% waitedmore than 2 hours. Thus, several problems werenoted: pain assessment was lacking, suboptimal useand dosing of opioids existed, and patients experi-enced a delay in receiving pain medication.

Emergency MMedicine PPractice© 2 July 2006 • EBMedPractice.net

Table 1: Resources For Guidelines/PoliciesPertinent To Pain Management

¾ ACEP Clinical Policies: http://acep.org/webportal/ PracticeResources/PolicyStatements/{ Pain Management in the Emergency

Department (Figure 1, page 3)� Non-traumatic acute abdominal pain� Acute headache� Procedural sedation in the ED� The Use of Pediatric Sedation and

Analgesia

¾ Cochrane Pain, Palliative and Supportive Care Group: http://www.cochrane.org/reviews/en/topics/85.html#topic_6{ 108 listings for acute management of specific

entities� Drug treatments for pain in sickle cell disease� Hydromorphone for acute and chronic pain� Opioid switching to improve pain relief and

drug tolerability� Oral morphine for cancer pain

¾ National Guideline Clearinghouse: http://www.guideline.gov/search/detailedsearch.aspx{ 107 guidelines for management of specific

entities

¾ Institute for Clinical Systems Improvement (ICSI): http://www.icsi.org/knowledge/detail.asp?catID=29&itemID=152{ Health Care Guideline: Assessment and

Management of Acute Pain

Lewis et al in 1994, performed a retrospectivereview of ED acute fracture management from 8 hos-pitals; they found that oligoanalgesia was ubiquitouswith no difference between urban versus suburbanor teaching versus non-teaching hospitals. Only30% of patients received analgesics during their EDvisits. Neither fracture location nor patient age werefound to significantly impact the decision to provideanalgesia. This study has limitations in that itsdesign was retrospective and pain scales were notused. Though it could be argued that those patientswho did not receive pain medication were not expe-riencing significant pain, this study contributed to agrowing body of evidence that physicians were fail-ing to meet the analgesic needs of their patients.

Patients with fractures were twice as likely to getpain medication as patients without fractures, evenwhen the level of reported pain was match con-trolled. 8 This represents a bias that sprains are not aspainful as fractures. Ducharme and Barber in 1995,performed a prospective blinded study on ED painassessment and therapy. 9 They described a lack ofuse of an objective scale or documentation of patientimpression of pain, and a less than 25% rate of“intervention or medication” for pain. Similarly, in1999, Tanabe and Buschmann documented only a15% use of opioids in a prospective study on pain inthe ED. 10 In 2002, Singer and Thode reported thathalf of patients with burns did not receive analgesiawhile in the ED, and almost half of the patients didnot have their pain severity assessed. 11 It is apparentthat oligoanalgesia and lack of pain assessment gohand in hand. It can be concluded that, if cliniciansdo not ask patients about their pain, it is unlikelythat pain medications will be provided.

A prospective study by Kozlowski et al lookingat analgesic use found that patients with isolatedlower limb fractures seen by physicians were threetimes more likely to receive analgesia than those seenby physician assistants.8 This was a single institutionstudy and the difference found in prescribing pat-terns between physicians and PAs cannot necessarilybe extrapolated to other practice environments.

Todd et al in 2003, designed a study to assesspain etiologies, patient pain experiences, pain man-agement strategies, and patient satisfaction using aquestionnaire and a chart review. Only 50% ofpatients received an analgesic, including 63% ofpatients reporting severe pain. Despite 69% ofpatients reporting that ED staff discussed the impor-tance of pain management with them, 88% of those

patients who did not receive pain medication did notask for analgesia. This may be due to a lack of expec-tation on the part of the patient for pain control.Forty-eight percent of patients were in moderate orsevere pain at discharge, yet the majority of patientswere either satisfied or very satisfied with their painmanagement. 5 These findings are surprising andmay highlight the fact that patients have low expec-tations for pain control versus some other undeter-mined factors. In the study by Ducharme andBarber previously described, patient satisfaction washigh despite a very low rate of pain intervention. 9

Oligoanalgesia in the elderly merits special men-

EBMedPractice.net • July 2006 3 Emergency MMedicine PPractice©

Figure 1: ACEP Policy StatementPain Management in the Emergency Department

The majority of emergency department (ED) patientsrequire treatment for painful medical conditions orinjuries. The American College of EmergencyPhysicians recognizes the importance of effectivelymanaging ED patients who are experiencing painand supports the following principles. • ED patients should receive expeditious pain man-

agement, avoiding delays such as those relatedto diagnostic testing or consultation.

• Hospitals should develop unique strategies thatwill optimize ED patient pain management usingboth narcotic and non-narcotic medications.

• ED policies and procedures should support thesafe utilization and prescription writing of painmedications in the ED.

• Effective physician and patient educational strate-gies should be developed regarding pain man-agement, including the use of pain therapyadjuncts and how to minimize pain after disposi-tion from the ED.

• Ongoing research in the area of ED patient painmanagement should be conducted.

Used with permission from the American College of EmergencyPhysicians.

Table 2: Factors Contributing To Oligoanalgesia

� A pre-occupation with the diagnosis and treat-ment of the underlying medical problem

� Concerns about masking symptoms� Fears about contributing to or causing addiction� Caregiver underestimation of pain experienced by

patient� Cultural differences in pain expression� Poor communication� Reluctance of patients to complain of pain or

demand pain treatment� A pain-free interval after acute traumatic injuries � Inadequate training in the recognition and man-

agement of pain.

tion because emergency physicians have self report-ed discomfort in managing this group. 12 13 Elderlypatients with hip fractures are less likely than theiryounger counterparts with fractures to receive anal-gesia, 14 and patients with dementia have been report-ed to receive analgesia at rates below 25%, evenwhen reporting pain. 15, 16 At the other end of the spec-trum, neonates and young children with pain arealso often undertreated for a variety of reasons,including barriers to communication. In one obser-vational study of pediatric patients with a limb frac-ture, no patient was discharged with a prescriptionfor pain medication. 17 Complicating communicationbarriers between children and physicians is theobservation that parents may also underestimate clin-ically significant pain in their children; this is accen-tuated if the child has a cognitive impairment.18 19

When the cognitive impairment is severe, the parentstend to appreciate the child’s pain. However, whenthe cognitive impairment is mild, parents tend tobelieve their children are overreacting to painfulstimuli. 19 Without the parents’ advocacy for theirchild’s pain, physicians are at an even greater disad-vantage when addressing pain control.

It is clear that the concept of oligoanalgesia is sup-ported by the literature. It is present across all patientpopulations. Knowledge of this makes it imperativeto design and develop strategies to improve our man-agement of pain. Using pain scales that allow patientsto rate their pain is an important first step.

Epidemiology And Practice Patterns

Pain relief is the reason for 20% of doctor visits, yetonly 0.6% of the National Institutes of Health’s(NIH) budget is devoted to basic and clinical painresearch. 20 Studies on the prevalence of pain in theED range from 52% to 78% of patients. 10, 21, 22 Giventhe ubiquity of pain complaints amongst patientspresenting to the ED, physicians may perceive thatdrug-seeking behavior is more common than it actu-ally is. One study in an ED seeing 75,000 visits peryear, estimated that less than 0.5% of patientsrequesting pain relief were “drug seekers.” 23

Economically, it is estimated that pain costs society$61.2 billion annually in lost productivity. 24

Acute pain and chronic pain are common com-plaints. Chronic pain is an epidemic and poses adaily challenge for the practicing emergency physi-cian. Indeed, EMTALA identifies pain as an emer-gent condition, however, it is unclear how to address

those with a chronic condition; there is limited dataon the epidemiology of acute conditions superim-posed on chronic states. There are no studies thatdocument the frequency of patients coming to theemergency department out of frustration due to inad-equate pain control for a chronic condition. That said,50% or more of the general population self-reportsbeing in chronic pain. 25 Common etiologies of chronicpain include low back pain (40% of the population) 26

and migraine (15% of the population). 27 Patients withchronic conditions can have acute disease as well:patients with chronic low back pain can have anacute disc herniation, and patients with a history ofmigraine can develop a subarachnoid hemorrhage.

The Canadian Association of EmergencyPhysicians held a consensus conference on emer-gency pain management in 1993 and published theproceedings as a consensus paper in 1994. After anextensive literature review, one of their findings wasthat health care workers often “underestimatepatient suffering.” 28 Since then, several studies havelooked at this issue. In 1999, Singer et al prospec-tively assessed patient versus practitioner assess-ments of pain from commonly performed proceduresand found that the correlation was poor to fair. Thisstudy highlighted the poor use of local anesthesia forcommon painful procedures such as nasogastrictubes and foley catheters. 29

In 2002, Guru and Dubinsky looked at patientversus caregiver perception of acute pain in the ED,as well as patient satisfaction. It was an observation-al, prospective study in which nurses, physicians,and patients rated pain levels using the VAS andNRS (see discussion of “pain scales” that follow).They found that nurse and physician ratings of painwere lower than the patient’s own rating of theirpain. In this study, 68% of patients with severe painreceived analgesic medication, with 49% of patientsexperiencing no pain relief. Interestingly, 50% of sat-isfied patients had no pain relief. There was nophysician-documented objective pain scale and onlyone physician documented patient response to med-ication. 30 Eder at al evaluated documentation ofpatient pain by a retrospective chart review of 261ED patients and found that, while the majority ofcharts contained an initial pain assessment, only 23%of charts used a pain scale. Response to therapy wasnoted on 39% of charts; however, again, pain scaleuse was low at 19%. Patients with severe pain onarrival, those with chest pain, and those whorequired “powerful analgesics” were more likely to


receive a subsequent pain assessment. Nurses were2.2 times more likely to document pain assessmentsafter treatment than physicians. 31 As with the studyby Guru and Dubinsky, this study calls to attentionthe need for reassessment of pain after intervention.It is possible that physicians are reassessing, butthese studies show that documentation is lacking.Pain assessment scales give patients the opportunityto express the level of pain they are experiencingand, thus, play a crucial role in providing appropri-ate pain treatment. 30 Health care providers canbecome desensitized to a patient’s pain given the factthat the majority of patients seeking medical care inthe ED have a pain-related complaint. Re-assess-ment allows the provider to remain aware of thepatient’s level of pain. A pre-formatted chart withpain scales could facilitate re-evaluation and shouldbe considered. 31

Pathophysiology

Pain is influenced by many factors. The AmericanAcademy of Pediatrics along with the AmericanPain Society, Task Force on Pain in Infants, Children,and Adolescents emphasizes that, “Pain is an inher-ently subjective experience and should be assessedand treated as such. Pain has sensory, emotional,cognitive, and behavioral components that are inter-related with environmental, developmental, sociocul-tural, and contextual factors.” 32 Pain is influenced byage, 33-35 race, 36 gender, 34, 35 and culture.37, 38

There are two categories of pain: Acute andchronic. Acute pain is usually associated with aninjury or pathologic condition (i.e., sore throat) thatgenerally resolves with the resolution of the incitingcause. Acute pain is mediated through nociceptorsthat fire in response to chemicals released during tis-sue damage, including leukotrienes, bradykinins,serotonin, histamine, and thromboxanes.Prostaglandins do not directly activate receptors;however, they act as a local mediator that enhancesthe sensitivity of the free nerve endings and producepain and edema by their vasodilatory effect. 39 40

Nociceptors can be found in the skin, periosteum,arterial walls, teeth, joint surfaces, and in the falxand tentorium of the cranial vault. 40 Nociceptorspropagate their impulses through the peripheralnerve to their cell body in the dorsal horn of thespinal cord to the spinal cord where Substance P (aneurotransmitter) is released, which then relays thesignal to the cortex via higher order neurons and the

spinothalamic tract. Pain functions as a biologicalarm system to signify tissue damage and preventfurther injury.

Additionally pain can be divided into somatic,visceral and neuropathic types. Noting the type ofpain will help not only in making the diagnosis, butalso in choosing the best therapy. Table 3, page 6,describes these types of pain, their mechanisms andeffective therapies. Somatic pain is often seen in theED and is straightforward.

Visceral pain is more complex and can be causedby ischemia, chemical stimulation and spasm, oroverdistention of a hollow viscus. 40 Afferent fibersfrom the affected organ converge on the same dorsalhorn neurons as the somatic afferent fibers, whichresults in referred pain to the cutaneous area inner-vated at that level. Additionally, primary visceralpain afferents usually course along with autonomicnerve fibers. Thus, visceral pain is often accompa-nied by autonomic symptoms such as nausea, vomit-ing, hypotension, bradycardia, and sweating.

Neuropathic pain is initiated by an injury or dys-function within the peripheral and/or central nerv-ous system. Nociceptive and neuropathic pain canoccur together. There are different types of pain thatpatients with neuropathic pain experience, see Table4, page 7. In neuropathic pain, symptoms are initial-ly experienced distal to the site of injury as opposedto nociceptive (somatic) pain, which is experiencedat the site of injury or inflammation.

Reflex Sympathetic Dystrophy (RSD) or complexregional pain syndrome type I (CRPSI), is a pain syn-drome thought to be of neuropathic origin. Giventhe complexity of this syndrome, the InternationalAssociation for the Study of Pain (IASP) has intro-duced criteria for diagnostic purposes, see Table 5,page 7. Mechanisms that have been described toexplain CRPS I include an excessive inflammatoryresponse from peripheral sensitization and anincreased responsiveness to input at the level of thedorsal horn neurons from central sensitization. 41

Chronic pain is pain which lasts longer thanwould be expected for a given injury or pathologiccondition. There are four types of pain seen inchronic pain conditions including: inflammatory,mechanical/compressive, neuropathic, and muscledysfunction, see Table 6 on page 7. Determiningthe mechanism involved can facilitate effective treat-ment. Remember that more than one mechanism canbe involved in a given patient. 42

Approximately 50% of diabetics will develop


neuropathy-related pain. Consequences of peripheralneuropathy in diabetics can be significant, includingthe development of a Charcot joint (hypertrophicarthropathy of the foot). Post-stroke neuropathicpain is seen in patients who develop pain in thesame territory of the stroke. Skeletal muscle pain is acommon cause of chronic pain and is a frequentdiagnosis in pain clinics. Inflammatory pain involvesinflammatory chemicals, e.g., prostaglandins, thatdirectly stimulate the primary sensory nerves carry-ing pain information to the spinal cord. Mechanicalor compressive pain is also a type of nociceptive painin that mechanical pressure or stretching directlystimulates the pain sensitive neurons.

Early treatment of acute pain is important:repeated applications of noxious stimuli result inincreased peripheral nociceptor responsiveness. Aprocess known as “wind-up” occurs when there is aprogressive increase in the output from dorsal hornneurons in response to repetitive inputs that areclose together. This results in pain amplification.The initial response to a noxious stimulus is briefand causes a sharp, well-localized pain. Then, thereis a more prolonged phase that is experienced as adull, diffuse pain. A prolonged exposure to tissueinjury can lead to sensitization of certain nerves in

the pain pathways, which can lead to persistent painafter the initial condition has resolved.3 Beneficialsymptom reduction may occur by preventing the ini-tial neural cascade and thus eliminating the hyper-sensitivity produced by the noxious stimuli: Thisphenomenon has been named “preemptive analge-sia.” 43 44 The concept of preemptive analgesia hasbeen studied in the context of post-operative painmanagement. A recent meta-analysis by Ong et alfound that preemptive analgesia with epidural anal-gesia, local anesthesia, and NSAIDs resulted in con-sistent improvements in all three outcomes whenresults were combined for all three outcome meas-ures (analgesic consumption, time to first rescueanalgesic request, postoperative pain scores). 45

Prehospital Care

There is very little in the literature on pain control inthe prehospital setting. A Pubmed search simply forthe terms prehospital and pain only returned 293English language articles since 1974. Very few ofthese articles were on the subject of pain control.

Authors agree that pain is an important issue inthe prehospital arena and that it is largely over-looked. Mclean made a conservative estimate that

20% of patients transported by EMS had mod-erate to severe pain. 46 Prehospital care is animportant window during which pain shouldbe assessed and treated. When prehospitalcare has focused on pain control, patients havehad a significant reduction in time to painrelief. 47 Yet, there can be significant hesitationin giving prehospital analgesia. One studyfound that patients with femoral neck fractureswere not likely to receive any analgesia, evenwhen requested. 48

There is disagreement as to whether or notchildren are less likely to receive prehospitalanalgesia, although no one argues the need forimprovement in this population. A retrospec-tive study in 2005 found that children andadults were equally likely (or unlikely) toreceive prehospital analgesia for lower extremi-ty fractures, and both groups had better rates oftreatment in the ED. 49 However, a second studyfound children were less likely than adults toreceive prehospital treatment, 50 and a NewZealand study reported that younger childrenare even more at risk for under-treatment. 51

With much room for improvement, even


simple interventions have been beneficial forpatients. An educational intervention in Chicagowas productive in raising awareness of pain, asmeasured by improved documentation amongstparamedics. 52 Simple non-pharmacologic interven-tions may be useful. Active warming has reducedthe discomfort of back pain during transportationwithout the risks or complications of medical inter-vention. 53 Since EMS crews vary in their level oftraining by location, non-pharmacologic interven-tions have the advantage of being easier to imple-ment across systems.

With regard to pharmacologic intervention, moststudies have focused on the roles of morphine, fen-tanyl, and nitrous oxide. A retrospective chart reviewof 2129 patients from Colorado found that fentanylwas safe and effective in the field. 54 However, thenovelty of use by paramedics, the difficulty of broadimplementation, the relationship between EMS crewsand medical control, and expense will vary acrosssystems and may be logistically difficult to duplicate.In addition, since morphine and fentanyl are equallyefficacious in the treatment of pain, 55 the cost of fen-tanyl over morphine would not outweigh the benefitin most prehospital settings.

Since the 1980s, authors advocated the use of 50%nitrous oxide by first responders as a safe and effec-tive option for pain control when IV opiates are notan option. A few reviews and editorials have contin-ued to advocate its use, but there are no current stud-ies that assess its availability or breadth of use. 56-58

ED Management

Initial stabilizationPatients presenting to the ED in acute pain often lookquite distressed. As mentioned previously, visceralpain is often accompanied by autonomic symptomssuch as nausea/vomiting, hypotension, bradycardia,and sweating. Initial stabilization requires immediateassessment of the presenting symptoms and vital signsand consideration for placement of an IV for titrationof pain medication. The type of pain dictates what isneeded for stabilization; e.g., substernal chest pain in adiabetic would require an IV, oxygen and monitor,while a recurrent tension type headache might requirenothing more than intramuscular medication.

An assessment and documentation of pain is afundamental component of triage. While manyacutely painful processes are not life-threatening,severe pain mandates a more urgent triage scoring


Table 5: IASP Criteria For Reflex SympatheticDystrophy (RSD) / Complex Regional

Pain Syndrome Type I (CRPSI)

1. The presence of an initiating noxious event, or acause of immobilization.

2. Continuing pain, allodynia, or hyperalgesia inwhich the pain is disproportionate to any incitingevent.

3. Evidence at some time of edema, changes in skinblood flow, or abnormal sudomotor activity in theregion of pain.

4. This diagnosis is excluded by the existence ofconditions that would otherwise account for thedegree of pain and dysfunction.

NOTE: Criteria 2 through 4 must be satisfied, the presence of an initiat-ing event is not required. Atrophy (of hair, nails, and other soft tissues),alterations in hair growth, loss of joint mobility, impairment of motor func-tion, and sympathetically maintained pain may be associated signs andsymptoms but are not used for diagnosis.

From: Ribbers: Arch Phys Med Rehabil, Volume 84(1).2003.141-6; Ghaiet al: J Postgrad Med, Volume 50(4).2004.300-307

Table 4: Neuropathic Pain: Definitions

• Allodynia: Painless stimuli that are experiencedas pain

• Hyperalgesia: An amplified response to a nox-ious stimulus

• Paresthesias: Spontaneous pins and needlesensation

• Dysesthesias: Unpleasant perception of sensorystimuli to skin

Table 6: Chronic Pain

¾ Inflammatory� Nociceptive pain� Arthritis, infection, tissue injury, and postopera-

tive pain� Heat, redness, and swelling at the pain site� History of injury or known inflammation

¾ Mechanical/compressive� Nociceptive pain� Neck and back pain� Muscle/ligament strain/sprain, fracture, degener-

ation of disks or facets, or osteoporosis withcompression fractures

¾ Neuropathic¾ Muscle dysfunction� Fibromyalgia and Myofascial Pain Syndrome� Sore, stiff, aching painful muscles and soft tis-

sues� Associated with fatigue, poor sleep, depression,

headaches, and irritable bowel syndrome

Adapted From: ICSI Guidelines: Assessment and Management ofChronic pain.2005.Available at www.icsi.org

and placement in the ED. Since early pain manage-ment may in fact break the cycle and limit the extentof pain ultimately experienced by the patient, earlypain control is recommended. In addition, early paincontrol can often facilitate obtaining an accurate his-tory and physical examination, see Table 7.

History

For patients presenting in pain, initial assessmentfocuses on whether or not an emergent conditionexists: treatment of pain should not be overlookedduring the initial evaluation and diagnostic work-up.A focused history should be obtained, including athorough PMH. It is also important to assess thecomponents of PMH that would affect the choice ofmedication, i.e., if a patient has a history of a bleed-ing ulcer, NSAIDs would not be a first choice.Another aspect in the evaluation of the patient inpain is the psychological component. Chronic painhas been associated with depression and a desire fora “hastened death.” 59 It is important to consider thepatient’s mood and affect, screening for signs ofdepression and suicidality as warranted. These emo-tional consequences of pain are also a reminder ofthe broad benefits to the patient when his pain iseffectively controlled.

PhysicalA focused physical exam includes vital signs, espe-cially pulse, respiratory rate, and blood pressure.Stressing the importance of pain assessment, theAmerican Pain Society has coined the phrase, “Pain:the 5th vital sign.” Studies have shown a correlationbetween pain and changes in vital signs, but even inacute pain the vital signs are not necessarily abnor-mal. Tousignant-Laflamme et al demonstrated anincrease in resting heart rate with acutely painfulstimuli. 60 However, it is important to note that theupper limit of the 95% confidence intervals forpatient’s heart rates even at the height of acute painin this study were still less than 100 bpm (beats perminute). While there is typically a rise in heart ratewith pain, the values need not be abnormal. Self-report should therefore be considered more indica-tive of the presence of pain. However, observationof a patient’s response to pain (i.e., facial expression,guarding) may be all you have to go on in a pre-ver-bal or cognitively impaired patient.

The extent of the physical exam depends on thetype of pain; pain in an extremity directly related toan injury requires a limited exam while a patient witha nonspecific complaint of pain may require a com-prehensive, systematic exam. Patients with a com-plaint of headache require a meticulous exam of cra-nial nerves II, III, IV, and VI; consideration should alsobe given to examining the temporal artery and assess-ing for vertebral or carotid dissection. A complaint ofchest pain requires a careful assessment of the pulses,heart, and lungs specifically looking for evidence ofpneumothorax, pulmonary embolus, pneumonia,pericarditis, and aortic dissection; a careful skin examshould be done looking for evidence of herpes zoster.The differential diagnosis of abdominal pain is exten-sive and the clinician must carefully perform a com-prehensive evaluation in order not to miss diagnosticfindings. A complaint of back pain requires a full neu-rologic evaluation with a focus on bowel and bladderfunction, motor, sensory, and reflexes.

Pain Assessment Tools

A number of pain assessment tools have been devel-oped to help provide a quantitative assessment ofpain and a mechanism to assess response to inter-ventions, see Table 8. These tools have been shownto facilitate pain management. Silka et al studied theuse of a verbal pain score in trauma patients. Priorto the start of the study, the nursing staff was educat-


Table 7: History and Physical

History¾ History of present illness (HPI)

� Onset� Duration� Quality, character� Ameliorating and provoking factors� Patient rating if possible

¾ Current medications¾ Medication allergies¾ Past medical history

� Any past history of similar pain?• What treatment has helped in the past• What studies have been done

� Assess factors that would affect medication use• Liver disease• Renal disease• PUD

¾ Pyschological assessment ¾ Social history¾ Allergies

Physical Exam¾ Vital signs: Before and after pain medications¾ Pain score: Before and after treatment¾ Focused physical exam: System specific

depending on complaint ¾ Functional assessment

ed on the use of the pain scale, the importance ofrelaying this information to the attending physician,and a column was added to the chart to facilitatedocumentation. Reminder memos to the physiciansand nurses regarding the importance of document-ing pain scales was done twice monthly during thestudy period. They found a 73% rate of pain assess-ment compared to their previous rate of 18.5%. Sixtypercent of patients who had pain assessment scoresreceived analgesics compared to 33% of patientswithout pain scores. They concluded that the use ofa pain assessment tool increased the chance of anal-gesic use in patients with high levels of pain,although a Hawthorne effect probably accounted forsome of this improvement. 61

In 2001, Bijur et al tested the reliability of theVAS for the measurement of acute pain in the ED. 62

Patients were asked to rate their pain on a 100 mmmarked scale with extremes labeled as least possibleand worst possible pain at 1 minute intervals, blind-ed to their first response. This was a prospective,convenience sample of 96 patients. They found that

90% of ratings were within 9 mm of one another,concluding that the VAS is highly reliable for themeasurement of acute pain in the ED. Extrapolatingthese findings further, changes in pain intensity lessthan 10 mm may represent an error of the methodand should be interpreted with caution.

Several studies have tried to quantify the clinical-ly significant change in the VAS in an attempt toassess pain relief. “The minimum clinically signifi-cant difference in pain was defined as the meanchange in pain associated with a rating of ‘a littlemore pain’ or ‘a little less pain’.” 63 An initial studyby Todd et al in 1996 found that 13 mm represents theminimally clinically significant difference. 64 This wasvalidated by a study by Gallagher in 2001. 63 Oneadditional study by Kelly in 1998 found 9 mm to bethe clinically significant number; 35 however, the confi-dence interval overlapped with the prior two studies.

The Visual Analog Scale (VAS) has been usedextensively in clinical research and has been found tobe reliable and valid in the ED setting. 64 62 However,it requires the cognitive ability to translate a patient’slevel of pain into a distance measure and adequatelevels of visual acuity and motor function. TheNumerical Rating Scale (NRS) can be administeredverbally and is a familiar clinical tool. In 2003, Bijuret al compared the NRS to the VAS in the evaluationof acute pain in the ED. They found that the twomeasures strongly correlated with each other andconcluded that the NRS could be substituted for theVAS. 65 A Verbal Descriptor Scale (VDS) is useful forthose patients unable to rate their pain on the NRS.NRS and VDS were validated in an ED population


• Use a pain scale in the triage assessment of pain.Consider pre-printed pain scales on charts forcompliance.

• The patient self report is the most reliable indicatorof pain severity.

• The basics, such as cold pack/elevation/ splint-ing/positioning, are important components ofeffective pain management.

• Treat pain early: use oral medications for lesssevere pain and IV medications titrated to painrelief for moderate/severe pain. Re-assess aftertreatment and document the pain score at dis-charge.

• Develop, document, and provide a pain manage-ment strategy at discharge.

Key Points

Table 8: Pain Scales

¾ NRS = eleven point Numerical Rating Scale (0-10)� 0 = no pain; 10 = unbearable pain (see

Figure 2)¾ GRS = Graphical Rating Scale (see Figure 3)¾ VAS = Visual Analog Scale

� Measurement of pain intensity for research pur-poses

� 100 mm (10 cm) line with "no pain" at left and"maximal pain" at right

� Requires cooperation of patient¾ VRS = Verbal Rating Scale

� Five pain levels in large print� No pain, mild pain, moderate pain, severe pain,

unbearable pain¾ VDS = Verbal Descriptor Scale

� No pain, mild, discomforting, distressing, horri-ble, excruciating (Tanabe)

¾ CHEOPS = Children's Hospital of Eastern Ontario Pain Scale (see Figure 4)

Figure 2: Numerical Pain Scale

by Tanabe. 10

In 1998, Berthier et al compared the VAS, theVerbal Rating Scale (VRS) and the NRS in measuringacute pain intensity in the ED. 66 They found that theVAS and NRS closely correlated in both trauma andnon-trauma patients. The VRS is less abstract, buthad an 11% non-response rate and poor differentia-tion between severe and unbearable pain in traumapatients. The VAS had a high non-response rate(39%) in trauma patients. The NRS had a very lownon-response rate, required only a verbal response,and was used successfully in 96% of patients. Theauthors concluded that the NRS is the preferableform of self-evaluation of pain in the ED.66

These various scales for pain assessment havebeen validated in the ED setting. Equally importantis their value in assessing clinical improvement. Animprovement of 13 mm on the VAS, as discussedabove, has been shown to be the minimum changenecessary to correlate to clinical significance.Likewise, a change of 1.39 on the NRS has beenshown to correlate to the same minimum clinicallysignificant change. In conclusion, while both scalesare valuable in the initial assessment of pain, they arealso valuable in the assessment of pain relief. 67

In 2005, Fosnocht et al reported that, while therewas a moderate correlation between the change inVAS and a verbal descriptor of pain, there was awide variability of change in the VAS so they cau-tioned against the use of a change in VAS as an indi-cator of pain relief for individual patients. 68 The VASis not a true interval scale and a change in painintensity at the lower range may not correlate with asimilar change in the higher pain range. This wasfurther evaluated by Bird and Dickson who reportedthat clinically significant changes in pain were notuniform along the entire VAS: “Patients with greaterpain required a larger change in VAS score to effect aclinically significant reduction or increase in per-ceived pain.” 69

Despite the availability of different assessmenttools, it has been documented that they are underuti-lized. In 1995, Ducharme and Barber performed aprospective, blinded observational study on painassessment in the ED. 9 They found that none of thepatients in the study had their level of pain docu-mented in the chart and that there was no use of anobjective pain scale. Ten out of 42 patients receivedsome intervention for pain, but only four received ananalgesic. Patients in severe pain waited an averageof 66 minutes to be seen, then an additional 74 min-

utes for medication. Tanabe found that pain scaleswere not routinely used, unless the patient was com-plaining of chest pain. 10

Various pain assessment tools are available for chil-dren who are old enough to communicate. Pain scaleshave been developed using numbers, colors, and facialexpressions, see Figure 3. 70 In preverbal children, sev-

eral pain scales have been validated. The CHEOPS(Children’s Hospital of Eastern Ontario Pain Scale) 71 isa well-validated tool for the assessment of pain in chil-dren, see Figure 4. It was initially developed for post-surgical patients, but has been used broadly since.72

The complete assessment includes a rating on verbal-ization and complaints, but the other five behaviors areappropriate for preverbal children. It quantifies painby rating five behaviors: crying, facial expression, ver-balization, activity of torso, touching, and extremityresponse, such as drawing up legs or squirming.

The assessment of pain in children unable tocommunicate, either because of age or cognitiveimpairment, is still more challenging for the clinician.The Non-communicating Children’s Pain Checklistassesses pain by scoring multiple parameters: vocal,social interaction, facial expressions, level of activity,body movements, or guarding and physiologic signssuch as shivering, sweating, or breath holding. 73

As in adults, self-reporting is the preferredmethod for assessment of pain in children. Whileeven very young children can give some indicationas to the pain they are experiencing, it is importantto assess for competence, especially between the agesof three and seven, to describe their pain accurately.Observation should always accompany self-report-ing and may be the necessary alternative when self-report is unavailable or unreliable. 32

The American Geriatric Society (AGS) has pub-lished broad guidelines on the issues of pain manage-ment in older adults. Older patients, like all otherpatients, should self-report their pain and needs


Figure 3: Wong-Baker FACESPain Rating Scale

From Hockenberry MJ: Wong’s Essentials of Pediatric Nursing, ed 7, St. Louis, 2005,Mosby, P. 1301. Copyrighted by Mosby, Inc. Reprinted by permission.

which should be considered the most accurate assess-ment of pain. Clinical assessments and surrogatereports should only be used when patients are unableto express their needs themselves. Communicationdifficulties can exist, especially in elderly patientswho suffer from dementia or limitations from cere-bral infarcts. Therefore, various descriptions for pain

should be used, i.e., aching, burning, discomfort, etc.,when questioning patients. In non-vocal patients,indicators of pain, including moaning and crying,should be taken as indicators of pain. 74

The NRS has been in use in the ED for many yearsfor the evaluation of chest pain. It is easy to adminis-ter and only requires a verbal response from thepatient. Additionally, it does not require a special tem-plate to be reproduced on the chart. Given these factsand that it has been validated, 66, 67 it is the authors’ pre-ferred tool for assessment of pain in the ED. However,there are still some patients who will be unable toassign a number to their pain. Some patients requireverbal prompting or even pictorial facial expressions toaid in their description of their pain. The key point isnot to advocate one scale over the other, but to empha-size their consistent use in the ED and provide alterna-tives when a preferred method of assessment is notfeasible for a given clinical encounter.

Management

The management of acute pain depends on the etiol-ogy of the pain. The initial approach after stabiliza-tion includes the basics: immobilizing a fracture,applying cold compresses, or placing an NG tube fora small bowel obstruction. Table 3 on page 6 out-lines a methodology for approaching treatmentbased on the type of pain the patient is experiencing.

While NSAIDs and opioids are the mainstay formanaging the majority of types of pain, uniqueoptions exist for the treatment of neuropathic pain.As the pain message is processed, there is a release ofendogenous opiates, enkephalin and dynorphin, sero-tonin, and norepinephrine. It is at this level that tri-cyclic antidepressants work by preventing the reup-take of serotonin and norepinephrine. While theirexact mechanism is unknown, antidepressants alsoimprove sleep, mood, and anxiety in addition to pain.Anticonvulsants or membrane stabilizers (e.g., carba-mazepine, gabapentin) work at the peripheral nervemembrane, preventing the transmission of pain.Complaints of continuous burning may best respondto antidepressants, whereas lancinating complaintsmay best respond to anticonvulsants. The anticon-vulsant gabapentin, however, has been used in thetreatment of burning and episodic neuropathic pain.

AnalgesicsAcute pain: There are many medications at our disposalfor the management of pain in the emergency depart-


Figure 4: CHEOPS

The Children’s Hospital of Eastern Ontario Pain Scale From: Hennrikus: JBone Joint Surg Am, Volume 77-A(3).March , 1995.335-339

ment. Physicians are frequently concerned about thepotential for addiction when prescribing opiates; how-ever, there have been studies suggesting that addictionrarely evolves in the setting of painful conditions. 75 76

Tables 9 and 10 below and on page 13, provide anoverview of analgesics and dosing regimens.

The route of administration of medication shouldbe selected based on the severity of pain. In a patientwith mild to moderate pain, offering an oral dose ofthe planned discharge analgesic early in the patient’svisit in the ED not only addresses their pain, but offersthe opportunity to see how effective the medicationwill be. In patients with moderate to severe pain, anIV catheter should be placed so that IV opioids can begiven and titrated to an appropriate level of pain relief.28 There is a limited role of the IM route in acute painmanagement. Often, health care providers use the IMroute with the thought that IM dosing provides a morerapid onset of action and has greater analgesic proper-ties than oral dosing. However, the onset of action ofIM and oral medications can be similar as seen withtoradol. 77 IM dosing is problematic as it exhibits vari-able absorption, is painful, is not easy to titrate and hasthe potential for hematoma formation. Additionally, itis more expensive thanoral medication to admin-ister and poses a needle-stick risk to the careprovider. 78

Chronic pain: Chronic painwarrants special mention-ing. As previously dis-cussed, there are 4 typesof chronic pain. Using thetype of pain to guide ther-apy is prudent. See Table11 outlining therapeuticoptions . Many patientswith chronic pain have aprimary care physician ora pain specialist involvedin their care. Often thesepatients may have a “con-tract” with these physi-cians for the amount ofnarcotics that they use. Itis reasonable to consultwith that physician priorto prescribing narcotics iffeasible.

Five percent lidocaine patches for post-herpeticneuralgia have been described in multiple articles.The patches have provided significant relief topatients without any more side effects than placebo.79

Lidocaine patches have been studied for neuropathicpain of other etiologies as well. In one study,patients with a variety of pathologies including dia-betic polyneuropathy, post-surgical pain, and radicu-lopathy were treated with topical lidocaine patchesafter failing anti-depressant, anti-convulsant, anti-arrhythmic and opioid medications. Most patientshad a reduction in their pain without significant sideeffects. 80 Open-label studies also provide initial evi-dence that lidocaine patches may be beneficial in themanagement of myofascial pain and osteoarthritis,even when used as monotherapy.81-83 Using lidocainepatches has not been shown to cause significant sys-temic absorption, serum lidocaine levels remainedwell below those that cause anti-arrhythmic effects.There was no report of local loss of sensation. 84

Additionally, no toxicities were noted in eitherhealthy volunteers, patients with post-herpetic neu-ralgia or in patients with acute herpes zoster. 85


Alternative And Adjunctive Therapies

In addition to the pharmacologic interventions dis-cussed, there are important alternative therapies forthe management of acute pain. These alternativetherapies include physical, cognitive, and behavioralinterventions, see Table 12. 86 While some of these

may seem difficult to execute in the ED, they areimportant to understand because of the potentialapplication at home or upon admission.

When traditional therapies have failed or are oth-erwise undesirable, novel approaches need to be con-sidered. Altier et al have reviewed cases of patients

up to sixty-six years of age with chron-ic neuropathic pain who have had ini-tially promising results withmethadone. All of the patients hadfailed to be controlled with conven-tional analgesics. They only reviewedthirteen cases and recognize thatprospective studies are required todetermine its efficacy in this patientpopulation. 87 Topical opioids havebeen used for the management of painassociated with open wounds.Methadone powder for longer relief ofwound pain has been described in casereports. Pain was better controlled inpatients who had open, exudativewounds while those patients witheschars showed less response. 88

Intraarticular (IA) injection of opi-oids has been used after arthroscopicknee surgery with relief of pain. 89 IAinjection of opioids has also been stud-ied prospectively for pain control inosteoarthritis. Patients had relief up toseven days without any short-term orlong-term side effects. 90 Case reportshave noted up to two weeks of reliefwith IA opioid injections in patientswith chronic pain. 91

Topical tricyclic anti-depressantshave shown promising results for thecontrol of neuropathic pain in casereports and open label studies. 92, 93

However, two randomized, blinded,placebo-controlled studies have beendone, one with topical doxepin andthe other with topical amitriptyline.These studies have demonstratedmixed findings; one study found sig-nificant analgesia and the other foundno difference compared to placebo. 94, 95

Acupressure and acupuncture arebeyond the scope of this article.Literature on the benefit of these inter-ventions continues to provide conflict-


ing results. Consequently, considerable controversycontinues to exist and there is a need for definitivestudies. A recent systematic review on acupuncture,analyzed 162 publications and concluded that “somefindings are encouraging but others suggest that its(acupuncture) clinical effects mainly depend on aplacebo effect”. 96, 97

Special Population Considerations

PediatricsThere are important physiologic differences betweenchildren and adults that affect their response to painmedications. 98 Metabolism and clearance of drugsare different throughout infancy. Liver metabolismreaches full function by one month of age. Due tothe relatively large liver compared to body mass,metabolism may be increased from ages two to sixyears. 99 Drug elimination is also affected by the dif-ference in renal function. Renal blood flow, glomeru-lar filtration rate, and tubular secretion are allreduced during the first year of life, after which renalfunction is similar to that of adults. 100, 101

Besides the differences in metabolism and elimi-nation, the bioavailability of the drugs is different inchildren. Children have less body fat; therefore,water-soluble drugs are comparably more availablein the plasma. Similarly, since lipophilic drugs areredistributed to the fat in lesser proportion, they areavailable in higher concentrations in the plasma andfor a longer duration. 98 Drugs may affect the centralnervous system in children more than in adults dueto the fact that proportionately more of their cardiacoutput goes to the brain and more drugs and metabo-lites may cross the immature blood-brain barrier. 98

Decreased protein binding is another factor contribut-ing to a higher bioavailability of drugs in children.Drugs affected by protein-binding include opioidsand local anesthetics. 98, 100, 101

These differences are not just a review of secondyear physiology but are intended to alert the clinicianas to why children need close monitoring when givenmedications. The dynamic changes in physiologythroughout childhood make dosing difficult, evenwhen following milligram per kilogram dosing for-mulas. In order to safely prescribe pain medications

for children, drug references shouldbe available for physicians toreview, and patients should be care-fully monitored for both therapeuticbenefit and undesired side effects. 102

ElderlyFor over a decade, the NationalHospital Ambulatory Medical CareSurvey has tracked ED visits andthe demographics of patients pre-senting to them. Patients over theage of seventy-five consistentlyhave the highest number of visits,even as the overall population hasgrown in ED utilization. Visitsfrom nursing home facility patientsalso continue to rise. 103-107 Socialissues may contribute to elderlypatients choosing the ED for care.Reasons include the fact that theytend to have lower incomes, livealone, may be less educated, andhave difficulty accessing care byother avenues. 108 All of these fac-tors complicate the issues of painmanagement in the elderly popula-tion.


Table 11. Pharmacologic Treatment Of Neuropathic Pain

Pain is a common problem affecting the elderlypopulation. It has been estimated that 50% of inde-pendent-living senior citizens experience chronicpain and that 45 to 80% of patients living in long-term care facilities have pain. 109 The elderly presentto the ED with more conditions of high or immediateurgency, compared to younger patients. 110 The elder-ly presenting to the ED have, not surprisingly, moreco-morbid diseases 108 and presumably more complexdaily medical regimens. The addition of new med-ications in the ED makes for greater medical com-plexity for older adults. This has had a negativeeffect on patients understanding their medications.Pain medications were the second most commonlyadded medication, after antibiotics. 111

Elderly patients with a personal physician andthose with health insurance of any kind, have alower risk of severe pain; elderly patients who self-initiate treatment of their health problems have alower risk of frequent pain. 112 Conversely, thosepatients without a regular physician, without healthinsurance, and those relying on the physician fordirection have been reported to be at risk for fre-quent or severe pain.

The American Geriatric Society has made severalrecommendations for the management of pain in eld-erly patients. They have recommended acetamino-phen as the drug of choice for mild to moderate painand opioids for moderate to severe pain.Acetaminophen has been used with satisfactory painrelief and has a lower side effect profile than non-steroidal anti-inflammatory drugs (NSAIDs). 113, 114

Chronic Pain and Drug SeekersMany EPs consider the management of pain in cer-tain patients to be one of the more trying aspects ofclinical practice. Different physicians may experi-ence this frustration in different subsets of patients,but frequently it includes patients who have chronicpain, those who are thought to be drug-seeking, andthose who choose the ED as their venue of choice tohave their pain treated. There are various character-istics to the practice of emergency medicine thatmake it vulnerable to abuse by patients: Anonymityof patients, difficult access to medical records, multi-ple EDs within a given city, and an obligation to seeand stabilize anyone complaining of pain.

Opiate-dependent patients are also a challengingpopulation to care for. Because of their dependence,the patient may have a different response to painfulconditions and may require higher doses of medica-

tion than physicians are accustomed to using.Suspicion of these patients may lead to a failure todiagnose significant conditions (e.g., epiduralabscesses or necrotizing fasciitis), making manage-ment especially challenging. Confounding the carefor these patients, is the high incidence of concurrentpsychiatric disease; indeed, one study reported thatpatients with opioid-treated chronic pain and con-current psychiatric disease have a 32% incidence ofsubstance abuse. 115 Intervention with a multidiscipli-nary team can improve pain scores and facilitate acomprehensive management stategy; however, thisapproach if often not feasible in a busy ED. 115

Health PolicyPain management has become an active issue inhealth care policy over the last decade. The Pain Relief Promotion Act of 2000 was drafted bythe House of Representatives. There are two titleswithin this act: Title I, “Promoting PainManagement and Palliative Care” which amends thePublic Health Service Act to require the director ofthe Agency for Healthcare Research and Quality topromote and advance scientific understanding of,and collect and disseminate protocols and evidence-based practices regarding pain management and pal-liative care …authorizes the Secretary of Health andHuman Services to award grants, cooperative agree-ments, and contracts for the development and imple-mentation of programs to provide education andtraining to health care professionals in pain manage-ment and palliative care.” Title II: “Use of ControlledSubstances Consistent With the ControlledSubstances Act” which amends the Controlled


Table 12

Physical interventions� Cold therapy� Massage� Careful positioning of the affected area

Cognitive interventions� Emotional support and information� Imagination� Hypnosis� Music� Play

Behavioral interventions� Relaxation techniques� Coping techniques� Biofeedback� Breathing control� Distraction, such as television, materials to

read, or toys for children


Substances Act to declare that, for that Act and anyimplementing regulations, alleviating pain or discom-fort in the usual course of professional practice is alegitimate medical purpose for the dispensing, dis-tributing, or administering of a controlled substancethat is consistent with public health and safety, evenif it may increase the risk of death.” 116

More recently, the National Pain Care Policy Actof 2005 was introduced in the House ofRepresentatives to “Declare adequate pain careresearch, education, and treatment as national publichealth priorities and for other purposes.” One of thegoals is to establish within the NIH a National Centerfor Pain and Palliative Care Research. While both ofthese acts are still in committee, their existence high-lights the recognition that pain management is anarea in need of improvement that can only occurthrough research and education. 117

Regulations, acts, and laws have significantimpact on the practice of medicine. The federal gov-ernment does not directly control the practice of med-icine; this is done by the states. However, the federalgovernment does directly regulate controlled sub-stances through other means. The Drug EnforcementAgency empowered by the Controlled Substances Actfrom 1970 is primarily concerned with the illicit useand diversion of controlled substances. 118 The federalgovernment also influences the practice of medicineindirectly through various agencies and laws, such asthe Joint Commission on Accreditation of HealthcareOrganization (JCAHO) standards and the enactmentof Emergency Medical Treatment and Labor Act(EMTALA), both of which address issues of pain.The direct control of the practice of medicine is doneby the states. It is important for physicians to beaware of their own state regulations and statutes,which differ with regards to the balance betweenadmonition to providers to relieve pain and obliga-tion through controlled substance legislation.

The pain relief act of 1996, which encouraged thenecessary use of opioids for the management of pain,did not actually set regulations for the practice ofmedicine. It was intended to serve as a model forstate legislators to follow. Many states have fol-lowed suit and have passed pain relief legislationthat follows the model of the federal act. Generally,the various state acts encourage the use of pain man-agement guidelines. The guidelines are not meant toserve as standards of care, but to protect physiciansand other providers from prosecution when follow-ing the guidelines. 118 However, this protection has

only been minimally addressed in the courts. A fewrecent cases have treated pain management as anobligation by the provider. One family successfullysued a nurse and a nursing home who withheld painmedication from a terminally ill patient for fear thathe would become addicted. 119

JCAHO has been committed to the improvementof pain management for some time. In 1999, theymandated that hospitals treat pain as the “fifth vitalsign.” 120 In 2001, they issued new standards requir-ing assessment and control of pain. These standardsdo not tell institutions how to manage pain, butrequire that a pain policy be in place and that painassessment occur. They recommended that pain beassessed on initial contact, when care is transferredfrom one setting or provider to another, after anyintervention, at regular intervals, and immediatelybefore discharge. 121 Additionally, they recommendthe use of a pain scale appropriate to the patientpopulation being treated.

In 2002, JCAHO teamed with the AmericanMedical Association (AMA) and National Committeefor Quality Assurance (NCQA) to “Develop a com-mon set of evidence-based measures for evaluatingthe appropriateness and effectiveness of pain man-agement.” Through convening an expert panel ofpain management experts, their goal was to helphealth care institutions and practitioners determinehow well they are managing individual’s pain. 122

Moreover, effective pain management hasbecome a priority for our specialty. The AmericanCollege of Emergency Physicians (ACEP) issued apolicy statement in 2004. 123 (Figure 1, page 3)Additionally, ACEP has established a clinical policyfor the use of narcotic analgesia in patients withabdominal pain.124 While there is no specific guide-line, they offer the option of providing narcotics topatients in the ED with abdominal pain. This topicis discussed further in the section on “Controversiesin Pain Management.”

Cutting Edge / Controversies

The Use Of Narcotics In UndifferentiatedAbdominal PainThe initial warning statement in Cope’s EarlyDiagnosis of the Acute Abdomen against the use ofpain medication in patients with abdominal painwas not evidence-based, yet became dogma that hasbeen hard to overcome. 125 At the time, 1921, it wasnot unusual to use morphine in doses of 30 mg, thus,

it was more likely to render the patient difficult toarouse, let alone examine. 126

There are now multiple studies in the literaturethat contradict this dogma. Zoltie and Cust per-formed a prospective, double-blinded study in 1986comparing buprenorphine sublingual versus placebo.The physical exam did change; however, in 18 of 50patients studied with a change in exam, the changeinvolved a localization of pain which facilitated thediagnosis. They concluded that buprenorphine canbe safely given to patients with an acute abdomen. 127

In 1992, Attard et al conducted a prospective,randomized, placebo-controlled study evaluatingintramuscular papaveretum (dose equivalent to mor-phine 12.5 mg) versus placebo. VAS and abdominalexam were done prior to medication and one hourlater. The study assessed the examiner’s confidencein diagnosis and management decisions before andafter treatment. Median pain and tenderness scoresfell significantly after papaveretum versus placebo,with no change in localization of the tender area.Interestingly, there were six unnecessary operationsin the placebo group and none in the study group.There were two patients in the study group whowere discharged and subsequently diagnosed withappendicitis. The surgical registrar’s confidence indiagnosing and making management decisions werenot altered by papaveretum. They concluded thatearly pain relief with papaveretum in patients withsevere acute abdominal pain did not have anyadverse effect on diagnosis. 128

In 1996, Pace and Burke evaluated IV morphinecompared to placebo in patients with acute abdomi-nal pain. They looked at changes in pain scoresbefore and after drug administration and at the accu-racy of the initial diagnosis compared with the finaldiagnosis. The morphine group reported significant-ly less pain. Treatment with morphine did not resultin resolution of peritoneal signs. The primary andfinal diagnosis agreed in 80% of patients in the mor-phine group and in 61% of patients in the placebogroup. Three patients in each group were misdiag-nosed. The authors concluded that administration ofmorphine to adult patients with acute, atraumaticabdominal pain resulted in pain relief without alter-ing the ability of emergency physicians to performaccurate evaluations. 129

In 1997, LoVecchio et al studied morphine (5 mgand 10 mg) compared to placebo in patients withabdominal pain. The study evaluated changes in thephysical exam, including changes in tenderness from

two or more quadrants to one, or loss of rebound ten-derness, and vice versa. Their results showed a signif-icant reduction in pain after both low and high dosesof morphine. Nine of 19 patients changed their physi-cal exam after high dose morphine, seven of 13patients with low dose morphine, and only one of 16patient in the placebo group. There was no morbidityor delay in patient care. The authors concluded thatearly administration of opiate analgesics is safe andeffective in patients with acute abdominal pain in theED. The authors theorized that the change in examwas due to muscular relaxation with decreased guard-ing with better localization. 126

Finally, in 2003, Thomas et al performed aprospective, randomized trial evaluating adultpatients with undifferentiated abdominal pain, com-paring placebo with morphine. They concluded thatthere was no “untoward effect” with early adminis-tration of morphine, and “No evidence supportingthe contention that [morphine] administration wasdeleterious in any way.” 130

Despite the fact that these five randomized, dou-ble-blinded studies support the use of analgesics innon-specified abdominal pain, clinical practice haslagged. In 1999, Tanabe found that only 35% ofpatients with abdominal pain received an analgesic.10

A survey of surgeons by Graber et al in 1999 foundthat 53% of general surgeons “Believe that pain med-ications preclude a patient from signing a validinformed consent” and 67% believe that “Narcoticscan hinder diagnostic accuracy.” 131 Wolfe et al sur-veyed emergency physicians in 1997 and found that,while 85% of physicians felt that pain medication didnot change “important physical findings,” 76% ofphysicians chose not to administer narcotics until thepatient was seen by a surgeon. Factors associatedwith whether or not medication was given included:The degree of pain that the patient was experiencing(69%), the certainty of diagnosis (52%), and thelength of time until surgical evaluation (58%). 132

In 2003, Kim et al surveyed pediatric emergency(PEM) physicians and pediatric surgeons and foundthat, in physicians with greater than 10 years experi-ence, pediatric surgeons were less likely than PEM -physicians to give narcotics (61% vs. 38%), with PEMphysicians citing disapproval by pediatric surgeonsas the main barrier for prescribing analgesics. 133 Thisdid not hold true for physicians with less than 10years experience. This likely speaks to the fact thatphysicians who have trained in the last 10 yearstrained during the time when the dogma of with-


holding pain medication in the evaluation of abdom-inal pain has been questioned and refuted. Theavailability and use of CT scan for the diagnosis ofabdominal pain likely also contributes.

An audit by Tait et al in 1999 found that 43% ofpatients with abdominal pain were admitted to thehospital without receiving an analgesic in the EDand had an average wait time of 5.7 hours for painmedication. 134 Similarly, a prospective observationalstudy by Shabbir et al in 2004 of patients presentingto the ED with abdominal pain demonstrated that67% of patients received pain medicine within onehour, but 22% waited from two to 14 hours. Thosepatients with less severe pain waited longer andfemale patients also had a longer wait than men,mean 129 minutes versus 69 minutes respectively. 135

These last two studies demonstrate that, while theliterature supports the use of narcotic medication inthe evaluation of abdominal pain, clinical practice hasnot yet changed. There are still a significant numberof patients admitted to the hospital who do notreceive pain medication, and patients who wait longperiods of time prior to pain medication. Developingcollaborative protocols for the management of acute,non-traumatic abdominal pain would seem prudent.

On a final note, capacity to give informed con-sent for potential surgical interventions occasionallyemerges as a weak argument against initiating paintreatment prior to an evaluation by a surgeon.However, it can be argued that pain itself cloudsjudgment, that patients in severe pain can think ofnothing but their pain and will agree to anything forthe relief of pain. 136 Hence, it would be coercive towithhold pain medication until informed consent hasbeen signed. Physicians should document, whenappropriate, the necessity of giving pain medicationsbefore consent and the patient’s cognitive state whendeciding, or else document that the delay in pain-control was necessary and tolerable in order toobtain proper consent.

Intramuscular Ketorolac Versus Oral IbuprofenNSAIDs inhibit prostaglandin synthesis and thus areespecially useful in pain syndromes where pain isprostaglandin-mediated, such as dysmenorrhea, bil-iary colic, renal colic, arthritis, postoperative pain,pharyngitis, and soft tissue trauma. 137 Some physi-cians prefer to use IM toradol rather than oral ibupro-fen. However, IM dosing does not have a faster onsetof action than oral dosing, and has several potentialcomplications. Wright et al published a retrospective

analysis of data collected during a prospective studyon pain management in which ketorolac, 60 mg IM,was compared to ibuprofen, 800 mg PO. A VAS toolwas used to assess pain pre- and post-treatment.There was no statistical difference in pain relief bychange in VAS score or by descriptive assessment. Infact, approximately 40% of patients in both groupsdescribed pain relief as none or little. 138

In a randomized, prospective double-blindedstudy, Turturro et al compared IM ketorolac (60 mg)and oral ibuprofen (800 mg) in acute musculoskeletalpain using a VAS instrument. 137 The level of pain wasevaluated at baseline, 15, 30, 45, 60, 75, 90, and 120minutes after dosing. Mean pain scores did not differbetween the groups and they concluded that IMketorolac and PO ibuprofen provides similar analgesia.

A third study looking at IM ketorolac and oralibuprofen was done by Neighbor and Puntillo. 139 Itwas a prospective, randomized, double-blindedstudy of patients with moderate to severe pain usinga NRS tool to assess pain at baseline, 15, 30, 45, 60,90, and 120 minutes after treatment. Supplementalanalgesics were allowed. No difference was notedbetween the two groups. An additional study byShrestha et al compared IM ketorolac and oralindomethacin in the treatment of acute gouty arthri-tis. This prospective, randomized, double-blinded,controlled study found no difference in pain relief. 140

There has been concern that the above studiesfailed to control for the presumed placebo-effect thatan IM injection has on a patient’s perceived painrelief; however, this would only further favor the useof oral dosing over IM. Regardless, one study didattempt to control for this potential placebo effect byusing saline injections in the group receiving oralibuprofen and starch tablets in the group receivingIM ketorolac; no difference in pain relief betweenoral and IM dosing was found. 78

It can be concluded from these studies that thereis no significant pain relief benefit of using IMketorolac instead of oral ibuprofen. In that IM dos-ing has theoretical risks and is more expensive, theuse of oral ibuprofen is clearly the best choice.However, when the parenteral route is required (i.e.,the patient is vomiting), there is a role for IM toradol.

Cox-2 InhibitorsCox-2 inhibitors were developed and introduced in anattempt to find an anti-inflammatory drug that wouldnot carry the anti-thrombotic properties of the non-specific cyclooxygenase inhibitors. From the time of


their introduction, refocoxib (Vioxx™ from Merck) andcelecoxib (Celebrex™ from Pfizer) grew to incrediblepopularity. In 2003, Cox-2 inhibitors were the seventhlargest selling class of drugs, with over five billion dol-lars in annual sales. 141 Eric Topol published a nowfamous challenge to the safety of Cox-2 inhibitors inJAMA in 2001 asserting that Cox-2 inhibitors did notshare the same anti-thrombotic properties of non-selec-tive Cox inhibitors, and that there was an increasedrisk of cardiovascular events. 142 Upon review of thestudies submitted to the FDA for approval of the Cox-2 inhibitors, he discovered that patients treated withrefocoxib in the Vioxx™ Gastrointestinal OutcomesResearch Study (VIGOR; 8076 patients) had anincreased risk of adverse cardiovascular events,including myocardial infarction and ischemic stroke,than patients treated with naprosyn. The Celecoxib™Long-term Arthritis Safety Study (CLASS; 8059patients) did not find an increased risk of adverse car-diovascular events when celecoxib was compared toibuprofen and diclofenac (Voltaren™).142 The differ-ence in the VIGOR study and the CLASS studyaccounts for the difference in the legal troubles thathave been faced by Merck and Pfizer.

While this has made headlines many times over,what goes unaddressed is the problem facingpatients who had found the COX-2 inhibitors to be agreat source of pain relief. It remains unclear whatare the best alternatives for these patients; severalauthors have recommended the use of traditionalNSAIDs with gastro-intestinal protection either with aproton-pump inhibitor or a histamine-2 receptorantagonist (H2RA). 143, 144 Elliott has suggested thattreatment with a H2 receptor antagonist is a cost effec-tive way to communicate the benefits of NSAID painrelief to patients while minimizing the risks of gas-trointestinal complications. 143 Other authors haveadvocated the continued use of COX-2 inhibitors inselect patients after careful screening. Given the cur-rent medico-legal climate, this could leave the pre-scribing physician in a precarious legal position andcareful documentation of counseling is recommended.

Disposition

Emergency physicians are well attuned to the need tomake a diagnosis whenever possible, the need toarrange for admission or follow-up, and the need toinform and educate the patient. Concurrent withthese familiar necessities, emergency physicians mustalso consider whether or not the patient’s pain has

been adequately controlled and develop a strategy forpain management if the patient is discharged home.

McIntosh and Leffler looked at the managementof pain after ED discharge for common acute orthope-dic injuries. A telephone questionnaire was doneseven to 14 days after discharge. Patients were ques-tioned about the type of medication received or pre-scribed from the ED, the filling of prescriptions, sideeffects of medications, interventions by other healthcare professionals, and the adequacy of pain relief inthe ED and after discharge. Additionally, they werequestioned regarding the operation of vehicles whiletaking their prescribed medications. Seventeen per-cent of patients did not fill their prescriptions; one-half of non-steroidal anti-inflammatory drug prescrip-tions were not filled; 7% of patients drove while tak-ing their medications. This study reports a high levelof satisfaction with pain control, with 67% to 92% ofpatients describing their pain control as adequate.The least satisfied were those patients who did not filltheir prescriptions, while those who were most satis-fied were discharged with a “starter pack” of 5 tabletsof acetaminophen/oxycodone. 145 Not all patientsleave the ED satisfied: Johnson et al reported that themajority of patients presenting with pain leave the EDwith “unresolved or worse pain.” 21 The discrepancybetween Johnson’s study and McIntosh’s most likelyis due to the type of pain studied and highlights theneed for developing appropriate pain managementdischarge strategies including follow-up.

Re-assessment of pain should occur at discharge.Keep in mind that there might be an early pain freeperiod with acute injury and that a patient who ini-tially was fine, may subsequently benefit from ananalgesic. It is best to write a prescription for a painmedication even if the patient is not experiencingpain, as it will likely be needed later. NSAIDs, whencombined with aspirin or alcohol, may predispose topeptic ulcer disease (PUD) and should only be usedin certain patients with caution. 146 If patients are notalready on prophylaxis for PUD, it should be consid-ered when using NSAIDs. 147 Although renal functionis not always checked in the ED before prescribingNSAIDs, prostaglandin inhibition decreases vascularflow to the kidney and the glomerular filtration rate(GFR). 147 Baseline renal function should be consid-ered for elderly patients, especially if a high orstanding dose of NSAIDs is being considered. 148

Authors have suggested NSAIDs only be used withcaution in asthmatics and in patients takingangiotensin converting enzyme (ACE) inhibitors,


angiotensin II receptor blockers (ARBs), or diuretics,since they may already have compromise to theirrenal function. The suggestion is not based on inter-action between the medications but on limiting theiatrogenic insult to renal function. 147, 149

Acetaminophen, previously mentioned in thediscussion of elderly patients, as a drug of choice fortreatment of mild pain in the elderly population hasa low side effect profile. However, at high doses,acetaminophen can cause an elevation in the interna-tional normalized ratio (INR) in those patients takingcoumadin. Hylek et al found that patients takingcoumadin had a ten-fold increase in their risk forsupratherapeutic INR when taking over 9100mg/week of acetaminophen. 150 When patients aredischarged with acetaminophen, discharge instruc-tions should include close follow-up with a recheckof their INR. Additionally, should a patient be dis-charged on an opiate/acetaminophen combination,education regarding the avoidance of additionalacetaminophen products should occur.

Opiates can be effective for treating moderate tosevere pain, but complications should be consideredand anticipated. Constipation is a frequent sideeffect. A bowel regimen should be initiated whenanalgesics are prescribed, including: adequate fluidintake, exercise, and consideration of an osmotic,

stimulant, or motility agent in some patients.Patients should be instructed to avoid bulkingagents. In discharge instructions, patients should beadvised of potential constipation and encouraged toseek follow-up evaluation. Patients should also becautioned not to drive while taking narcotics, andwarned about the risk of falls. Additionally, medica-tion-induced pruritis can be treated with an anti-his-tamine and nausea with an anti-emetic agent. 148

In geriatric patients, pain should be evaluated inthe context of their overall physical functioning. 74

Patients may already have a compromised ability intheir activities of daily living and may be moreseverely restricted by painful conditions. Patientswho previously lived independently may not be ableto care for themselves effectively nor safely with newpainful symptoms. Involvement of family membersor social workers may be necessary to facilitate the discharge of an elderly patient. It is also importantto understand that pain is not only undertreated inthe ED, but oligoanalgesia is ubiquitous in the med-ical community. When discharging an elderlypatient back to a nursing facility, a multidisciplinaryassessment and management approach should beencouraged. 74 While such assessments are outside ofthe typical practice in the ED, it can be an important

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Inform patients about generic options.Many pharmacies will automatically substitute ageneric drug (i.e., oxycodone/acetaminophen whenPercocet™ is prescribed) while filling a prescription;however, patients may not know to look for genericbrands of over-the-counter drugs. It is a commonhabit to refer to TylenolTM or MotrinTM when speakingto patients, but reminding them that acetaminophenand ibuprofen are the same medications can savethem money when they purchase their medications.

Consider using oral medications instead of IV.When patients are intolerant to oral medication theremay be no option but to use IV or IM medications.However, if a patient can tolerate oral medications,their administration is less expensive than the par-enteral routes. Additionally, it allows assessment ofthe effectiveness of oral pain control for dischargeplanning and may decrease return visits to the ED.

Consider using a traditional NSAID and GI protec-tion instead of a COX-2 inhibitor.It is increasingly difficult to prescribe a COX-2inhibitor since refocoxib has been withdrawn fromthe worldwide market and valdecoxib has been with-drawn from the market in the United States.Celebrex™ is still available, although physiciansshould weigh carefully two factors before prescribingthe medication. First, is it safe for this patient to use?Even though there has not been the same evidence oncelecoxib increasing cardiovascular risk as has beenpublicized on refocoxib – the potential risks shouldstill be strongly considered. Patients may be betterserved by taking a traditional NSAID and either aproton-pump inhibitor or H2-blocker for gastroin-testinal protection. Secondly, physicians should alsoconsider their own liability when prescribing a COX-2 inhibitor, given the legal climate that has surround-ed the two drugs no longer available.

Cost Effective Strategies


1. “The patient had abdominal pain, but I did’tgive any pain medication because I did notwant to mask the exam.”

Pain control should be considered in everyencounter, even in patients with abdominal pain.When the patient is more comfortable, theabdominal exam can yield more information.The signs of serious pathology will not becomeunrecognizable, and it is still possible to followthe evolution of the pain.

2. “The vital signs were normal, so even though hesaid he was in pain there wasn’t any evidencethat it was true.”

Vital signs may be normal and yet patients maystill be in significant pain. Common medications,such as beta-blockers, may interfere with the nor-mal stress response. And even in the absence ofinterfering medications, vital signs are not a reli-able predictor of pain severity. A patient’s ownreporting is the most reliable means of assessingthe intensity of pain.

3. “I didn’t give narcotics because I was afraid hewould get addicted.”

There is no evidence that patients treated foracute pain with narcotics are at increased risk ofaddiction. The trends in federal and state legisla-tions have also pushed the standard of caretoward an obligation to treat, and the liabilitymay be greater for not treating than for beinglean on pain control.

4. “The patient was not in pain at the time of dis-charge, so pain control did not need to beaddressed.”

Patients may not experience the most intensepain for their conditions at the time of presenta-tion. Some processes, such as the inflammatoryresponse, may increase after the time of dis-charge. The progress of the patient’s conditionshould always be considered and the patientshould be discharged with pain medication.

5. “The patient was an IV drug abuser; I knew hewas just looking for pain medications, so I senthim right out.”

Patients who abuse IV drugs are at risk for veryserious pathology, such as epidural abscess andnecrotizing fasciitis, both of which typically pres-ent with complaints of pain. Regardless of apatient’s experience with narcotics, he will needto be evaluated every time he is seen in the ED.

6. “The parents did not think the child was in pain,so I stopped thinking about pain control at thatpoint.”

Parents underestimate the pain their childrenexperience just as badly as physicians do. It isimportant to look for signs that parents may notnotice, such as grimacing, guarding, drawing uptheir legs, or squirming. Certainly, any childcomplaining of pain needs to be taken seriously.

7. “She was an IV drug abuser, so I gave her thepain meds I would have given anyone else.When her pain wasn’t controlled I told her thatwas her problem.”

Patients who are tolerant of opiates, eitherbecause of recreational use or from chronic paintreatment regimens, may require more medica-tion that opiate-naive patients. The actual dosesshould not be the primary concern, but rather thebalance of therapeutic benefit and the risks ofhigher doses.

8. “I made the diagnosis, which is my priority.What difference does it make if I treated theirpain?”

Making the diagnosis is one of the most impor-tant services provided by emergency physicians,but there is still an obligation to stabilize thepatient’s pain. Many patients’ reporting of satis-faction is based not only on accurate diagnosisand treatment but also on the overall patient-provider interaction, including pain control.

9. “The patient was too demented to even know ifhe was in pain, he didn’t need medication.”

Non-verbal patients may be in significant paindespite their inability to communicate it.Physicians should be attuned to other signs ofpain, such as moaning, crying, or writhing.

10. “She was allergic to everything but meperidine,that’s when I knew she was a drug-seeker.”

Patients may not understand what constitutes atrue allergy. Itching is common when taking nar-cotics because of the histamine release. Whenpatients list allergies, physicians should explorewhat is meant. Sometimes, medications may belisted because of misunderstanding. Even if thepatient insists on allergies to all other medica-tions, she should still be evaluated for pathologyand a need for real pain control.

Ten Pitfalls To Avoid

(continued from page 20)

recommendation on discharge paperwork.It is important to treat a patient’s pain, relying

on their self-report and erring on the side of painrelief. However, it becomes apparent over time withcertain patients that their visits are highly suspiciousfor drug-seeking behavior. This can become obviouswhen a patient has multiple visits for either multipledifferent painful conditions or multiple visits for thesame complaint. Some EDs keep a file on “frequentfliers” or have a system for posting special concerns.Red flags can also include documentation of callsfrom a pharmacy to confirm prescriptions, calling tolight that a patient may be filling prescriptions frommultiple physicians. In these cases, discharge timemay be the best time to notify the patient that the EDis best used to manage patients with acute pain andthat further management of their chronic pain is bestmanaged by a pain specialist. A referral to a paincenter for further follow-up is recommended.

Future Directions: Improving EDPain Management

EducationThere is little formal education on pain managementas noted by Selbst and Clark in 1990. 151

Astonishingly, Bonica, in a 1985 text, reviewed 25,000pages in 50 major textbooks for medicine, surgery,pediatrics, and emergency medicine and found only54 pages devoted to the management of pain. 152

Additionally, few medical schools include acute paincontrol in their core curriculum. 153

In 1998, Chan and Verdile looked prospectively atpatient satisfaction with pain control by 48-hour fol-low-up surveys. This study was done approximatelythree years after the institution of an annual one-hourlecture on pain management for emergency medicineresidents and four required sessions annually for staffphysicians and nurses on patient satisfaction, focus-ing on awareness and treatment of pain. They founda high (91%) satisfaction rate and a high rate of anal-gesic prescriptions (95%). These rates are higher thanthat previously described in the literature. Educationof staff and residents may be the difference. 154

In 1999, Jones prospectively assessed a pain edu-cation program for EM residents. A study includinga questionnaire and serial VAS scores was conductedbefore and after the institution of a four-hour painmanagement program for the residents. There was

an improvement in patient’s 30-minute pain reduc-tion from 65% to 92% of patients. 152

The problem with pain control in the pediatricpopulation is not the difficulty of controlling pain,but the inconsistency with which analgesia isoffered. Patient assessment, which addresses pain,can prompt the treatment of pain. Pain is consistent-ly reduced when there are supportive measures inplace and when pediatric-focused annual nurse com-petencies are used. 155

It is clear that this is an area in need of develop-ment. Better education of resident physicians, staffphysicians, and nurses on the issues surroundingpain management is paramount to improvingpatient’s pain relief with the added benefit of proba-ble improved patient satisfaction.

Conclusion

The patient in the case vignette had sickle cell diseaseand had become tolerant to narcotics. He receivedoligoanalgesia for his pain and the treating physicianfailed to put his acute presentation in context with hischronic disease. The complaint from the patient wentboth to the ED medical director and to the patient’shematologist who forwarded a second complaint thathe had not been informed of the patient ED visit orconsulted on how to best manage the pain and ensurenext day follow-up. The system failed and, in thiscase, the patient paid the price.

Many physicians have been too quick to labelpatients as “drug-seekers” when the patients arereally seeking relief. Many physicians have under-treated pain or have not become knowledgeableabout the variety of therapies available. While painrelief may not be perceived as the primary mission ofthe ED, there exists a great opportunity and manyresources to intervene and assist the patient in need.Pain control must take place along side diagnosis,intervention, and education. Even as the stresses ofcrowded departments and sick patients bear downon emergency physicians, if pain control is kept inmind, patients will “Cry out in good earnest, ‘At lastI yield to an effective science.’” (Michel De Montaigne)

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CME Questions

1. Oligoanalgesia means:a. Health care providers manage pain in their

own style.b. Not every patient in pain requires pain med-

ication.c. Patients in pain are often under-treated.d. Patients in pain minimize their symptoms.

2. The following statements regarding pain aretrue, EXCEPT:

a. Pain is prevalent in the ED and ranges from52 to 78% of patients.

b. Reassessment of pain is extremely importantin the management of pain in the ED.

c. Pain is a common problem affecting the elder-ly population.

d. Untreated pain can result in increased painthrough the upregulation of nerve fibers lead-ing to an increased stimulation of the painpathway.

e. Patients with chronic pain do not requireassessment and treatment in the ED.

3. A patient’s level of pain or pain experience:a. Is not related to the circumstances of injuryb. Is multi-factorialc. Is Irrelevant as long as the correct diagnosis is

made.d. Is unrelated to the type and extent of injurye. Doesn’t involve the physical and emotional

state of patient.


4. Chemicals involved in the pain pathway include:a. Leukotrienesb. Bradykininsc. Serotonind. Histaminee. All of the above

5. RSD (reflex sympathetic dystrophy) or complexregional pain syndrome type I (CRPS I):

a. Is a type of neuropathic painb. Pain is often proportional to inciting eventc. By definition, an initiating traumatic event is

requiredd. Pain is experienced proximal to the site of

injurye. There are never physical findings associated

with this diagnosis6. Visceral pain:

a. Is never accompanied by autonomic symp-toms such as nausea/vomiting, hypotension,bradycardia and sweating.

b. Can be caused by ischemia, chemical stimula-tion, spasm or overdistention of a hollow vis-cus.

c. Mediated through nociceptors found in theskin.

d. Is rarely encountered as a source of pain inthe ED.

e. Should not be treated with analgesic.7. Important tools available for the assessment of

pain include:a. Physician impression of painb. Numerical Rating Scalec. Visual Analog Scaled. Interpretation of vital signse. B and C

8. Reassessment of pain is important and should bedone:

a. Only at the initial contact with patient.b. Only if a family member or the patient

requests it.c. Only at the time of transfer of care to another

setting or provider.d. After any intervention.e. No more than twice because the ED is busy.

9. The best route for pain medication administra-tion and titration is:

a. Intravenousb. Intramuscularc. Orald. Transdermale. Sublingual

10. Neuropathic pain:a. Is not seen in diabetic patients.b. Often responds to standard therapy.c. May respond to treatment with tricyclic anti-

depressants.d. Does not respond to anticonvulsant therapy.e. is best treated with opioids.

11. NSAIDs:a. Are rarely used in the ED.b. Iinhibit prostaglandin synthesis.c. Should not be used in the treatment of dys-

menorrhea, biliary colic, renal colic, or arthri-tis.

d. IM toradol has been shown to be more effec-tive than oral ibuprofen.

e. Hhave no contraindications to their use.12. The following statements regarding intramuscu-

lar administration of medications are trueEXCEPT:

a. It is easy to titrate pain medication with theIM route.

b. It poses a potential needlestick risk to thehealth care provider.

c. It is more expensive.d. Its onset of action is similar to the oral route.e. Its primary indication is if a patient cannot

tolerate oral medication secondary to vomit-ing.

13. Which statement is true regarding the use of nar-cotic medications in patients with abdominalpain in the emergency department?

a. Narcotics can result in a change in exam, andthe change often makes the diagnosis moredifficult.

b. There are no studies in the literature that con-tradict the dogma of withholding narcotics inthe evaluation of abdominal pain in the ED.

c. Narcotics should be used in patients withabdominal pain in the ED while being evalu-ated.

d. Most patients admitted to the hospital withabdominal pain have received pain medica-tion.

e. ACEP has not addressed this issue with aclinical policy.

14. ACEP’s Policy Statement on Pain Management inthe Emergency Department includes allEXCEPT:

a. ED patients should receive expeditious painmanagement, except for necessary delayssuch as those related to diagnostic testing orconsultation.

b. Hospitals should develop unique strategiesthat will optimize ED patient pain manage-ment using both narcotic and non-narcoticmedications.

c. Effective physician and patient educationalstrategies should be developed regarding painmanagement, including the use of pain thera-py adjuncts and how to minimize pain afterdisposition from the ED.

d. Ongoing research in the area of ED patientpain management should be conducted.

e. ED policies and procedures should supportthe safe utilization and prescription writing ofpain medications in the ED.


15. What can we do to improve our management ofpain?

a. Continue what we are doing now.b. Educate our staff, residents, and medical stu-

dents about assessment and management ofpain.

c. Assess and reassess patient’s pain.d. Understand that pain is present in some form

in nearly every disease and recognize itsimportance.

e. All but a.16. Which statement is true regarding pain relief and

patient satisfaction?a. Pain relief means that the patient is satisfied

with their medical care.b. Patient satisfaction means that the patient

received adequate pain relief.c. Patient/physician interaction is not a factor.d. They are not synonymous.e. The level of reassurance that a patient has

experienced is unrelated to their level of satis-faction.


Class I• Always acceptable, safe• Definitely useful • Proven in both efficacy and

effectiveness

Level of Evidence: • One or more large prospective

studies are present (with rareexceptions)

• High-quality meta-analyses • Study results consistently positive

and compelling

Class II• Safe, acceptable• Probably useful

Level of Evidence: • Generally higher levels of evidence• Non-randomized or retrospective

studies: historic, cohort, or case-control studies

• Less robust RCTs• Results consistently positive

Class III• May be acceptable• Possibly useful• Considered optional or alternative

treatments

Level of Evidence:• Generally lower or intermediate

levels of evidence

• Case series, animal studies, con-sensus panels

• Occasionally positive results

Indeterminate• Continuing area of research• No recommendations until furtherresearch

Level of Evidence: • Evidence not available• Higher studies in progress • Results inconsistent, contradictory• Results not compelling

Significantly modified from: TheEmergency Cardiovascular CareCommittees of the American HeartAssociation and representativesfrom the resuscitation councils ofILCOR: How to Develop Evidence-Based Guidelines for EmergencyCardiac Care: Quality of Evidenceand Classes of Recommendations;also: Anonymous. Guidelines forcardiopulmonary resuscitation andemergency cardiac care. EmergencyCardiac Care Committee andSubcommittees, American HeartAssociation. Part IX. Ensuring effec-tiveness of community-wide emer-gency cardiac care. JAMA1992;268(16):2289-2295.

Physician CME InformationAccreditation: This activity has been planned and implemented in accordance with the

Essential Areas and Policies of the Accreditation Council for Continuing MedicalEducation (ACCME) through the joint sponsorship of Mount Sinai School of Medicineand Emergency Medicine Practice. Mount Sinai School of Medicine is accredited byAccreditation Council for Continuing Medical Education to provide continuing medicaleducation for physicians.

Target Audience: This enduring material is designed for emergency medicine clini-cians.

Needs Assessment: The need for this educational activity was determined by a surveyof medical staff, including the editorial board of this publication; review of morbidityand mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prioractivities for emergency physicians.

Date of Original Release: This issue of Emergency Medicine Practice was publishedJuly 31, 2006. This activity is eligible for CME credit through July 31, 2009. The latestreview of this material was July 30, 2006.

Discussion of Investigational Information: As part of the newsletter, faculty may bepresenting investigational information about pharmaceutical products that is outsideFood and Drug Administration approved labeling. Information presented as part ofthis activity is intended solely as continuing medical education and is not intended topromote off-label use of any pharmaceutical product. Disclosure of Off-Label Usage:This issue of Emergency Medicine Practice discusses no off-label use of any phar-maceutical product.

Credit Designation: The Mount Sinai School of Medicine designates this educationalactivity for a maximum of 48 AMA PRA Category 1 Credit(s)TM per year. Physiciansshould only claim credit commensurate with the extent of their participation in theactivity.

Faculty Disclosure: It is the policy of Mount Sinai School of Medicine to ensure fairobjectivity, balance, independence, transparency, and scientific rigor in all CME-spon-sored educational activities. All faculty participating in the planning or implementationof a sponsored activity are expected to disclose to the audience any relevant financialrelationships and to assist in resolving any conflict of interest that may arise from therelationship. Presenters must also make a meaningful disclosure to the audience oftheir discussions of unlabeled or unapproved drugs or devices. The informationreceived is as follows: Drs. Curtis, Morrell, Todd, and Godwin report no significantfinancial interest or other relationship with the manufacturer(s) of any commercialproduct(s) discussed in this educational presentation.

For further information, please see The Mount Sinai School of Medicine website atwww.mssm.edu/cme.

ACEP, AAFP, and AOA Accreditation: Emergency Medicine Practice is also approvedby the American College of Emergency Physicians for 48 hours of ACEP Category 1credit per annual subscription. Emergency Medicine Practice has been reviewed andis acceptable for up to 48 Prescribed credit hours per year by the American Academyof Family Physicians. Emergency Medicine Practice has been approved for 48Category 2B credit hours per year by the American Osteopathic Association.

Earning Credit: Two Convenient Methods• Print Subscription Semester Program: Paid subscribers with current and valid

licenses in the United States who read all CME articles during each EmergencyMedicine Practice six-month testing period, complete the post-test and the CMEEvaluation Form distributed with the December and June issues, and return it accord-ing to the published instructions are eligible for up to 4 hours of Category 1 credittoward the AMA Physician’s Recognition Award (PRA) for each issue. You must com-plete both the posttest and CME Evaluation Form to receive credit. Results will bekept confidential. CME certificates will be delivered to each participant scoring higherthan 70%.

• Online Single-Issue Program: Paid subscribers with current and valid licenses in theUnited States who read this Emergency Medicine Practice CME article and completethe online post-test and CME Evaluation Form at EBMedPractice.net are eligible forup to 4 hours of Category 1 credit toward the AMA Physician’s Recognition Award(PRA). You must complete both the post-test and CME Evaluation Form to receivecredit. Results will be kept confidential. CME certificates may be printed directly fromthe Web site to each participant scoring higher than 70%.

CEO: Robert Williford President and Publisher: Stephanie Williford

Direct all editorial or subscription-related questions to EB Medicine: 1-800-249-5770 • Fax: 1-770-500-1316 • Non-U.S. subscribers, call: 1-678-366-7933

EB Practice, LLC • 305 Windlake Court • Alpharetta, GA 30022

E-mail: [email protected] • Web Site: EBMedicine.net

Emergency Medicine Practice (ISSN Print: 1524-1971, ISSN Online: 1559-3908) is published monthly (12 times per year) by EB Practice, LLC, 305 Windlake Court, Alpharetta, GA 30022. Opinionsexpressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication is intended as a general guide and is intended to supple-ment, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used for making specific medical decisions. The materials contained hereinare not intended to establish policy, procedure, or standard of care. Emergency Medicine Practice is a trademark of EB Practice, LLC. Copyright .2006 EB Practice, LLC. All rights reserved. No partof this publication may be reproduced in any format without written consent of EB Practice, LLC. Subscription price: $299, U.S. funds. (Call for international shipping prices.)

Emergency Medicine Practice is not affiliated with any pharmaceutical firm or medical device manufacturer.

Class Of Evidence DefinitionsEach action in the clinical pathways section of Emergency MedicinePractice receives a score based on the following definitions.

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