Elsevier

Annals of Emergency Medicine

Volume 66, Issue 3, September 2015, Pages 246-252.e1
Annals of Emergency Medicine

Pain management and sedation/original research
Patient Perspectives of Acute Pain Management in the Era of the Opioid Epidemic

https://doi.org/10.1016/j.annemergmed.2015.03.025Get rights and content

Study objective

To inform the development of interventions that could improve patient engagement around the risks and benefits of alternative approaches to pain management in the emergency department (ED), we seek to capture the perspectives and experiences of patients treated for pain in this setting.

Methods

Three trained interviewers conducted semistructured open-ended telephone interviews with patients discharged from a single urban academic ED after presenting with acute pain related to fracture, renal colic, or musculoskeletal back injury. We recruited subjects until achieving thematic saturation according to periodic review of the interview transcripts. Interviews were audio recorded, professionally transcribed, and uploaded into QSR NVivo (version 10.0) for coding and analysis using modified grounded theory. An interdisciplinary team double coded the data and convened to review emerging themes, ensure interrater reliability, and establish consensus on discrepancies.

Results

We had 23 completed subject interviews, the majority of which were women. Interrater reliability for coding exceeded 90%. The major themes elicited centered on domains of patient awareness of the potential for opioid dependence and patient-provider communication relating to pain management. From the patient perspective, emergency physicians typically do not present alternative pain management options or discuss the risks of opioid dependence. Patients with negative experiences related to pain management describe deficiencies in patient-provider communication leading to misunderstanding of clinical diagnoses, fragmentation of care among their health care providers, and a desire to be involved in the decisionmaking process around their pain management. Patients with positive experiences commented on regular communication with their care team, rapid pain management, and the empathetic nature of their care providers. Patients communicate fears about the risks of opioid addiction, beliefs that following a prescribed opioid regimen is protective of developing opioid dependence, and an understanding of the broader tensions that providers face relating to the prescription of opioid therapy.

Conclusion

Patients identified a deficit of communication around opioid risk and pain management options in the ED.

Introduction

During the last 15 years, governing bodies such as the Joint Commission emphasized recognition of pain in patients, labeling pain assessment as a fifth vital sign.1, 2 The prevalence of pain as the presenting complaint in emergency departments (EDs) ranges between 38% and 78%.3, 4, 5 Up to 70% of patients with acute pain fail to receive any analgesics in the ED.6, 7, 8, 9 Previously noted barriers to adequate pain management included provider failure to acknowledge pain, failure to document pain, inadequate training on analgesia, and sociodemographic biases.10

Editor’s Capsule Summary

What is already known on this topic

Providers in the emergency department (ED) often give opioids to patients with pain. Little is known about patients' knowledge and perceptions about analgesia after a visit to the ED.

What question this study addressed

What are the patient perspectives on their care after an ED visit for acute pain?

What this study adds to our knowledge

Open-ended interviews with 23 patients with selected acute pain complaints at 1 urban ED revealed themes of opioid addiction fear, perceived lack of provider concern, and opportunity for better communication about analgesia options.

How this is relevant to clinical practice

If sustained by research in other settings and conditions, these observations will inform analgesic protocols and care plans in an ED, targeting the opportunities noted.

Criticism of emergency physicians for insufficiently treating pain now is crossing with concerns about an opioid epidemic, the latter accounting for the greatest number of current injury-related deaths in the United States.11, 12, 13 Emergency physicians are confronted with the challenge of how to alleviate pain in a manner appropriate and adequate, which requires balancing the analgesic needs of patients with the potential risks associated with opioid therapy, including diversion, misuse, and dependence.14 During the course of the last decade, the federal government through the National Drug Control Strategy pushed for a multipronged approach to address the opioid epidemic, deploying initiatives that focus on drug monitoring, proper opioid disposal, physician education, and law enforcement.15 Few of these initiatives examined or implemented interventions that engage patients around understanding of the risks and benefits associated with opioid and other alternative treatments.16 In the context of competing public health priorities presented by the 2 larger issues of patient oligoanalgesia and opioid misuse, the patient voice has been omitted.

We sought to inform potential patient-centered interventions that can both provide adequate pain management and decrease the potential for opioid misuse. We chose a qualitative approach to uncover patient perspectives and attitudes related to pain management in an ED setting.

Section snippets

Study Design and Setting

We conducted semistructured open-ended interviews with patients who presented to a single, urban, academic ED (annual census 64,000) with complaints of acute pain relating to renal colic, musculoskeletal back pain, or extremity fracture.17 Our institutional review board approved the study protocol and written consent for audiotaped interviews. We used the Consolidated Criteria for Reporting Qualitative Research to guide data collection, analysis, and reporting.18

Selection of Participants

Patient recruitment occurred

Characteristics of Study Subjects

We approached 74 eligible patients in the ED, 48 (65%) of whom agreed to complete a verbal survey related to their pain management. Of these, 36 subjects (75%) consented to follow up by telephone interview and 23 (64%) completed the telephone interview. Table 1 illustrates the characteristics of patients approached and those subjects who participated in the interview portion of the study. Most of the participants were women (18/23). There was variation in age, race, presenting complaint, yearly

Limitations

As is common to all qualitative research, our observations are exploratory, not definitive. We can generate or refine hypotheses for future interventions around pain management and communication in EDs. We chose a convenience sample of patients presenting to one ED with one of 3 common complaints known to cause acute pain; although these selected conditions present with distinct pain profiles and distinct risks for conversion to chronic pain, they may not reflect all possible patient

Discussion

The patient experience with acute pain in ED settings is affected by many complex factors. Although studies have aimed to quantify patient satisfaction with pain management in the ED, we uncovered some patient experiences and attitudes related to pain management, use of opioids, and understanding of the risks of developing opioid dependence. The patient’s overall experience is not guided by mere satisfaction or dissatisfaction with pain management. The dynamics of provider empathy, care

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  • Cited by (35)

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      As our findings suggest, simply restricting opioids for pain management on a general basis does nothing to mitigate risk for patients who must receive opioids, yet it sacrifices pain relief for patients who are not at-risk. Unrelieved pain may result in important health consequences (Blomqvist, 2003; Schwaller & Fitzgerald, 2014; Smith et al., 2015), and our findings are consistent with studies describing inadequate pain relief in the ED setting (Beel et al., 2000; Tanabe & Buschmann, 1999; Todd et al., 2007). Several participants described the potential of obtaining opioid medications for pain relief off the street, and upon chart review we found that two participants received emergency treatment for an opioid overdose during the 30-day window after their ED visit.

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      Many cancer patients improperly and unsafely store, use, or dispose of opioids, thus highlighting a need to investigate the degree and impact of patient education and counselling practices.21,22 A study about patient perspectives reveals gaps in prescriber-patient communication regarding opioid risks and pain management in the emergency departments.23 Primary care prescribers also have reported stress related to prescribing opioids, providing appropriate pain management, and communicating with patients regarding these topics.24

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    Please see page 247 for the Editor’s Capsule Summary of this article.

    Supervising editor: Donald M. Yealy, MD

    Author contributions: KR, JP and ZFM conceived the study and obtained research funding. RJS, BP, and SK undertook patient recruitment and data collection and management, including quality control. RJS conducted data analysis and drafted the article, and all authors contributed to its revision. ZFM takes responsibility for the paper as a whole.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist and provided the following details: Funding was provided by a grant from the Agency for Healthcare Quality and Research to Drs. Meisel and Rhodes in the Center for Emergency Care Policy & Research, R18HS021956.

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