Pain Management
Inadequate analgesia in emergency medicine

https://doi.org/10.1016/j.annemergmed.2003.11.019Get rights and content

Abstract

Review of emergency department pain management practices demonstrates pain treatment inconsistency and inadequacy that extends across all demographic groups. This inconsistency and inadequacy appears to stem from a multitude of potentially remediable practical and attitudinal barriers that include (1) a lack of educational emphasis on pain management practices in nursing and medical school curricula and postgraduate training programs; (2) inadequate or nonexistent clinical quality management programs that evaluate pain management; (3) a paucity of rigorous studies of populations with special needs that improve pain management in the emergency department, particularly in geriatric and pediatric patients; (4) clinicians' attitudes toward opioid analgesics that result in inappropriate diagnosis of drug-seeking behavior and inappropriate concern about addiction, even in patients who have obvious acutely painful conditions and request pain relief; (5) inappropriate concerns about the safety of opioids compared with nonsteroidal anti-inflammatory drugs that result in their underuse (opiophobia); (6) unappreciated cultural and sex differences in pain reporting by patients and interpretation of pain reporting by providers; and (7) bias and disbelief of pain reporting according to racial and ethnic stereotyping. This article reviews the literature that describes the prevalence and roots of oligoanalgesia in emergency medicine. It also discusses the regulatory efforts to address the problem and their effect on attitudes within the legal community.

Introduction

Inadequate pain management by the medical profession has been a recurrent and heated topic of discussion since a landmark 1973 article by Marks and Sachar.1 Marks and Sachar, psychiatrists routinely called on to evaluate drug-seeking behavior and addiction in hospitalized medical patients, concluded that the majority of the patients they examined simply had severe untreated pain. Their study contested the rationale that physicians offered to explain the stinginess of their prescribing habits, the belief that psychological addiction necessarily resulted from the regular use of opioid medications for pain control.1 Although this concern has been repeatedly debunked, this and similar attitudes that inhibit the adequate use of analgesics remain strongly entrenched in medical practice 30 years later.1, 2, 3

The nature of emergency department (ED) practice requires that emergency physicians be well versed in pain management strategies. A 1997 survey showed that 22% of 94.9 million ED visits resulted in pharmaceutic therapy for pain.4 Despite this large experience of pain-related visits, oligoanalgesia remains a serious problem in EDs and across the spectrum of medical settings in which patients seek relief from pain. The seemingly intractable resistance of this problem to solution suggests that its roots lie deeply entrenched in our health care culture and likely reflect fundamental attitudes of society in general, as well as those of health care workers.

Section snippets

Evidence of oligoanalgesia in emergency medicine

Studies of pain management began to appear in the emergency medicine literature around 1990. Most are retrospective studies of patients with acute conditions that are perceived by most to be painful. Although these studies differ in design and population surveyed, together they document a historical litany of oligoanalgesia across a broad demographic range of patients and practice settings. In one prospective study, opioid analgesics were prescribed to fewer than 1 in 5 ED patients who reported

Adequacy of training in the assessment and management of pain

The cumulative factors that contribute to a provider's willingness to provide analgesia may be partly affected by accuracy in assessment of pain severity. Underestimation of pain has been confirmed in several studies that compared patients' pain scales with caregivers' values for acute painful conditions.6, 20, 21, 22 Nurses tended to underestimate pain more often than physicians in 2 studies.20, 21

Underestimation of patients' pain by provider pain scores may in some cases simply reflect the

Attitudes about chronic pain

“Chronic noncancer pain” is defined as pain lasting at least 6 months “or of a duration longer than the expected time to tissue healing or resolution of the underlying disease process, or a condition where there is ongoing nociception.”31 There is a growing acknowledgment that patients with chronic pain are undertreated and that opioids have a significant role in the management of chronic pain, in conjunction with other nonopioid modalities.32 Evidence gathered by the World Health Organization

Other factors in medical culture that influence analgesia

Even when obvious causes of acute pain are identified, perceived causes of pain influence physicians' decisions to treat it. This concern is demonstrated in a study of acute pain by Friedland et al10 in pediatric patients described previously in which the medical culture and knowledge base of their institution support the use of analgesics in management of vaso-occlusive crisis but fail to recognize the need for analgesia in patients with burns and fractures.10 The importance of the cause of

Myths regarding the management of pain: competence and informed consent

Physicians' misconceptions about competence and informed consent result in convictions that treatment of pain will compromise patients' decisionmaking capacity, which commonly results in the withholding of pain medication, usually in surgical cases, until consent is obtained. “Competence” is a legal condition determined by the courts, the basis of which varies from state to state. The process of obtaining informed consent for medical interventions assumes competence and requires the

Mandated changes in institutional priorities

The US Department of Health and Human Services Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) was created in 1989 to address problems of health care access. This agency, which first published institutional guidelines for acute pain management in 1992, has made pain management a priority for more than a decade. Yet despite the prestige and visibility of this institution, most hospitals surveyed 1 year after the guidelines were published had

Pain research in the ED setting

Despite an explosion of analgesia research, indicated by more than 23,000 randomized, controlled trials reported in the Cochrane database, there have been few clinical trials specific to emergency medicine practice on which to establish an evidence-based approach. The challenge for emergency physicians is to identify data clinically relevant to the ED setting while fostering controlled, randomized studies within their own milieu.51 There is evidence that emergency medicine as a specialty is

Challenges of the study of the efficacy of pain relief

Perception and depth of pain appear to vary considerably among individuals. Some patients receive substantial relief from placebo; others require large doses of opioids to relieve pain. Surgeons in the military have long been aware that some soldiers wounded in battle do not require morphine for pain relief.53 We have all encountered patients with acute fractures who do not appear to have pain or indicate that they have pain when questioned. Animal studies have demonstrated genetic

Special cases: acute pain in the elderly patient

ED visits increased from 90.3 million to 107.5 million visits between 1996 and 2001, and persons aged 75 years and older had the highest rate of ED visits in any surveyed year.57, 58, 59, 60 Between 1980 and 2000, the number of patients older than 65 years and treated in all medical care settings increased from approximately 25 to 35 million.61 Patients older than 65 accounted for more than 13 million ED visits in 1990, a number that increased to 15 million in 1995.62, 63 A 1993 Medicare study

Treatment of the pediatric population: analgesia

In the emergency medicine literature, little attention has been paid to the treatment of acute pain in children. A recent extensive review of the ED treatment of pediatric orthopedic injuries did not mention the treatment of pain.70 Poor correlation between children's assessment of their own pain scores and those of their parents show that parents do as poorly as practitioners at judging the pain severity in their children.71 Parental lack of knowledge about the risks and benefits of pain

Treatment of the pediatric population: procedural sedation

Procedural analgesia allows us not only to treat acute pain but also to prevent it. Analgesics, sedatives, and anxiolytics may have additive effects when used during procedural sedation, including respiratory depression, apnea, chest-wall rigidity (parenteral fentanyl), myocardial depression, histamine release, and toxic metabolite formation (normeperidine).79, 80 Despite the potential for adverse events, the rate for adverse events during procedural sedation was only 2.3% in one study when

Drug-seeking patients

Emergency physicians frequently express concern that patients may manufacture complaints in an effort to receive opioid analgesics. There is no doubt that there are patients whose patterns of use of emergency services supports a diagnosis of drug addiction and drug seeking. Unique features of emergency medicine, namely 24-hour availability, brief physician-patient encounters, and limited access to medical records, create a significant potential for prescription drug abuse. Nevertheless,

Opiophobia

Society's attitudes toward opioids sometimes stray from the purely scientific and take on a moral tone that affects the conduct of the law, medical practitioners, and the public. Legitimate concerns about chronic addiction and abuse blend with moral distaste for the pleasures of opioid use and disdain for persons with psychological addiction to their euphoric effects. Such attitudes may be inappropriately directed toward persons who seek relief of pain, resulting in mistrust of the patient's

Cultural and sex differences in the assessment of pain

The decision to treat acute pain has been shown to be influenced not only by a patient's age but also by sex, language, and cultural differences between health care providers and patients; bias based on racial and ethnic stereotypes; and moral judgments about lifestyles or concerns about addiction.90, 91, 92, 93 In one study of ED patients with headache, neck pain, or back pain, female patients described more pain and were perceived by clinicians to be in more pain than male patients with

Medical-legal issues in pain management

Medical malpractice cases that allege failure to adequately manage pain have dealt with end-of-life cases. In 1990, a North Carolina court awarded $15 million to the family of a patient who, before his death, proved that he experienced intolerable pain from prostate cancer because of the failure of a nursing home nurse to administer ordered pain medications. She thought that he would become addicted.89 In 2001, a California Superior Court found a physician liable under the elder abuse laws for

Acknowledgements

We thank Irene Hargett for her invaluable assistance with preparing this manuscript. We also thank Connie Chen, PharmD, for her assistance in the preparation of this manuscript.

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    Supported in part by a grant from Pharmacia Incorporated, Global Outcomes Research, Skokie, IL.

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