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 Abstract
Pain is one of the most common reasons
why patients seek emergency care. It is
also one of the few areas a physician
can make a difference toward more
efficient patient care.
The assessment of pain in acute
situations involves the location,
quality and severity of the discomfort.
Patients' claims should be the sole
reference point when deciding whether to
administer analgesics or not. The
clinician must depend on the patient to
supply key information on the
characteristics of the pain. Analgesic
choice, dose and route of the
therapeutics should also be adjusted to
the individual requirements.
Acute pain conditions are underevaluated
and undertreated in emergency
departments (ED), suggesting that ED
staff need more education about acute
pain.
Many factors contribute to the
undertreatment of acute pain in the
emergency setting.
Fears of development of opioid tolerance
or addiction are not based on concrete
evidence in the acute setting, albeit
very common. Better education regarding
pain management and in-service training
can improve analgesic usage in trauma
centers and EDs.
In this report, the results of a
literature search involving inadequate
pain management in the acute situations
were outlined as a narrative review.
Key words (MeSH): Analgesia, pain,
emergency medicine, therapeutics, acute
disease.
Oligoanalgesia:
The Challenge in The Emergency
Department
Pain in the emergency department (ED)
In its definition of pain as 'an
unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage', the International
Association for the Study of Pain (IASP)
does not associate the perception of
pain with a stimulus, but emphasizes the
multidimensional nature of pain, with
its emotional, conceptual, judgmental
and motivational components (1). Acute
pain almost always responds to the
treatment of the underlying
condition(2). Acute pain generally lasts
for hours to days.
Pain is the most common presenting
complaint in the ED setting (3). Many
procedures and invasive diagnostic and
therapeutic procedures routinely carried
out in the ED are quite painful (4).
Expectations for full compliance with
the pain management standards of the
Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) began
in January 2001. In the JCAHO
guidelines, examples of implementation
of this standard in clinical practice
include the addition of pain as the
"fifth" vital sign to be noted in the
context of initial assessment; the use
of pain intensity ratings; and posting
of a statement on pain management in all
patient care areas (5). In the future,
JCAHO is anticipated to look for this
evidence of an organization's compliance
with the pain standards during the
accreditation process.
The term "oligoanalgesia" was first
pronounced by Wilson and Pendleton in
1989 (6). It is used to describe "too
little" analgesia and occurs when
physicians provide less than optimal
pain relief.
Assessment
of pain in the acutely ill
Pain is what the patient states it is. A
diverse spectrum of psychological,
sociocultural, temporal and situational
variables affects how people perceive
and express their pain. Age, sex,
ethnicity, accompanying psychiatric
problems and economic status of the
patient are among the factors that may
affect the way an individual expresses
his/her complaints. In an unblinded
study female patients tended to report
the severity of pain higher than males
did and received more pain medications
(7). Thus the painful experience becomes
a unique phenomenon for each patient,
thereby necessitating use of versatile
tools of assessment in the clinical
practice.
The assessment of
pain in the acute situation involves the
site, quality and severity of the
discomfort. Although some authors
advocated the use of physiological
parameters to evaluate the properties of
pain, they are more useful to verify a
clinical impression. Physiological clues
such as tachycardia, hypertension or
restlessness may help determine the
requirement for pain management in
intubated or incoherent patients(8).
Additional findings that suggest pain in
the unconscious patient may be
agitation, sweating, pallor, pupillary
dilatation, moaning, grimacing and
flinching(9). Abdominal and thoracic
pain results in decreased tidal volume,
vital capacity, and in turn, alveolar
hypoventilation(10). Intestinal
secretions increase and smooth muscle
sphincter tone is enhanced in the
gastrointestinal system. Increased
systemic vascular resistance and
alterations in sympathetic tone
resulting from pain may mask hypovolemia,
thus may preclude adequate fluid
resuscitation.
Some studies tried to measure and
investigate the characteristics of the
"clinically significant changes in pain"
using a Visual Analog Scale (VAS). The
term is used to define the magnitude of
the change in pain necessary to be
noticed clinically by the patient and
was reportedly measured as 13 mm on a
100 mm VAS (11), while
physician-perceived change was measured
as high as 18 mm(12). This phenomenon
may suggest physicians are somewhat
likely to underestimate the changes of
pain in their patients.
Oligoanalgesia
in the management of pain
Although pain is
commonly encountered, emergency
physicians are shown to fail to
recognize or properly treat pain(13-16).
This phenomenon is firstly referred to
as "oligoanalgesia" by Wilson and
Pendleton (6). Emergency patients at
risk for oligoanalgesia are outlined in
Table 1. Underuse of analgesia in
medical practice is reported in the
medical practice(17,18).
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Table 1:
ED patients at increased
risk for oligoanalgesia
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Many authors have emphasized that
suffering of patients with acute
conditions are unnecessarily protracted
in the EDs. In one of the most recent
studies, Silka, et al. reported that in
trauma patients the time to administer
the first dose of analgesics was 109
minutes(19). During the study period,
less than 40% of patients meeting trauma
center criteria received analgesic
agents in the ED. Patients with long
bone fractures, women, and those
spending more time in the ED were most
likely to receive analgesics. Patients
with head injuries commonly did not
receive analgesics. In a study of
fast-track patients, 60 percent of the
patients went home with more pain than
they were willing to accept(20).
Lindgren reported that most patients
undergoing foot or ankle radiographs
following traumatic injury receive no
pain medication in the ED (21). Patients
with fractures were found more likely to
receive analgesics. Lewis, et al, found
that only 30% of 401 patients with acute
fractures received analgesics while in
the ED (22). They pointed out that 41%
of patients admitted to the hospital
received analgesics while only 22% of
those discharged did. Jantos et al.
showed 11% of adults and 4% of children
with orthopedic trauma received pain
treatment while in the ED (12).
Due to the absence of objective
measures, the clinician must depend on
the patient to supply key information on
the localization, quality and severity
of the pain. The value of the patients
description of the location and nature
of the discomfort has been proved in the
context of formal teaching and routine
practice, though physicians frequently
question the reported severity and rely
on their own estimates (22). As a
result, healthcare providers generally
underestimate and undertreat the
patients' pain. Multiple reasons exist
for oligoanalgesia. It is a common
practice to withhold analgesics if an
alert patient does not ask for
painkiller medications. Age is also a
risk factor for oligoanalgesia (23).
Children, especially the younger ones
constitute a good example being "too
young to need analgesia" (24).
Various studies have investigated
administration of analgesics to patients
receiving acute care in the
ED(14,16,25,26). In a study with
pediatric trauma victims, only 53% of 99
patients with fractures were
administered analgesics in the ED(17).
In another study, sixty-six percent of
109 elderly emergency patients with long
bone fractures received analgesics
versus 80% of non-elderly victims (23).
Fifty-nine percent of female versus 41%
of male patients received analgesia
while in the ED (6). On the contrary,
there are studies indicating a tendency
to underestimate and undertreat pain in
female patients (27).
Several reasons for withholding
analgesics from patients in the acute
medical/surgical setting have been
suggested: possible masking of primary
symptoms(28); potential deleterious
physiological consequences of opioids
including hypotension, nausea and
vomiting, altered mental status, urinary
retention and constipation (25), and a
lack of priority among nurses and
physicians (26,28). The lack of priority
results largely from the failure of
medical education to stress the
essential role of pain treatment in the
overall management of the acutely ill
and injured. To date, few medical
schools have included acute control of
pain as part of a core curriculum. Thus
medical students may conclude that pain
control is not a priority. It has been
shown that pain management may improve
with just a few hours of focused
teaching(29). Nurses' knowledge deficits
were also accused as a source of
failures in pain treatment(30). Table 2
lists some misconceptions regarding pain
management which are common among health
care professionals. In the US, the
Agency for Health Care Policy and
Research stated that pain control
measures depend on cooperation between
all members of the health care team
throughout the patient's course of
treatment(31). A federally sponsored
guideline on the control of acute pain
has affected pain management in the
postoperative setting positively.
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Table 2:
Facts and myths that impair
pain management in the ED
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A related pitfall in the ED management
of pain is the fear of using opioids: "opiophobia".
A major reason for opiophobia is the
avoidance of causing uncontrollable side
effects in emergency patients, such as
respiratory depression, hypotension, or
oversedation. These are preventable with
adherence to basic rules of usage(32).
Respiratory depression is very unlikely
if titration to effect is used.
Furthermore, the emergency physicians
are capable of managing the patient in
extremis in these situations.
Although new opioid addiction in
emergency patients constitutes the
rationale for opiophobia, some studies
proved that iatrogenic opioid addiction
is too rare to anticipate e.g., zero to
4 cases per ten thousand hospitalized
patients receiving opioid analgesia were
detected(33,34). There are no published
reports of iatrogenic opioid addiction
beginning in the acute management in the
ED. Opioid tolerance, on the other hand,
can ensue in about three weeks of
continuous opioid administration. This
problem is not an issue in the ED.
In patients with chronic pain who are on
opioids, physical dependence and
tolerance can be anticipated(35).
Addiction to opioids is estimated to
occur in between 3% and 16% of patients
with chronic pain. Establishing a
diagnosis of opioid addiction requires
careful consideration of diverse
information regarding drug-seeking
behavior. Unless there is a diagnosis of
drug abuse or addiction, the clinician
should not withhold due medication for
fear of addiction or abuse.
Do
analgesics obscure the diagnosis?
Data obtained from reports in the early
20th century created a concern that
analgesic use is associated with blunted
findings on examination in case of acute
pain, e.g. acute abdominal conditions.
The truth is, instead, utilization of
opioids allows better cooperation and
thus can facilitate abdominal
examination. Excruciating or severe pain
may preclude a proper examination.
Tenderness is usually not affected by
analgesia while patients free of pain
would feel better (36). Some studies
demonstrated that it is a safe practice
to administer opioids in patients
suspected to harbor critical
illness(37,38). Furthermore, the
untoward effects of opioids can easily
and rapidly be counteracted by
antagonistic agents, e.g. naloxone. Need
for analgesia is clear and immediate
when there is no doubt on the diagnosis
or the patient is to undergo definitive
treatment, e.g. operation.
What
is recommended?
Conceptual considerations: Coman and
Kelly employed a nurse-managed, titrated
intravenous analgesia protocol with
opioids in 401 adult ED patients(39). A
total of adverse effects (17
hypotension, one hypersensitivity, one
vagal reaction) were observed. They
concluded that the protocol is a
well-used and safe method of providing
analgesia. More recently, Fry and
Holdgate corroborated these findings in
their study of 349 patients in whom
experienced ED nurses administered
intravenous morphine awaiting medical
assessment(40). The median time to
narcotic was 18 min and the median time
to be seen by a doctor was 50 min. The
procedure was appraised as improving
time to analgesia for patients in acute
pain.
Pharmacological considerations: although
there are many patients whose pain could
effectively be controlled with non-opioid
agents, opioids are the drugs of choice
for the control of severe acute pain.
As a general principle of pain
management, opioids should always be
titrated in reasonable quantities to a
pre-determined quantitative end-point,
while patients are monitored for adverse
effects. In general, administration of
intravenous opioids requires pulse
oximetry and close observation. The
physician should also keep in mind that
clinical observation is subjective and a
drop in pulse oximetry could be a late
sign. Non-invasive capnometry is more
rapid and thus should be the preferred
method to detect hypercapnia. Although
these are important considerations,
complications are quite rare, when
patients are carefully selected and the
choice, dose, route, and frequency of
opioid are individualized.
Other techniques: for some patterns of
injury, for example, isolated limb
fractures, regional anesthesia could be
undertaken. Stabilization of the trauma
patient via splinting may also aid in
pain relief. Local anesthesia
infiltrated into open wounds and
lacerations will also be helpful and
should be tailored to the patient's
situation(41). Furthermore, some
researchers reported music distraction
resulted in lower pain ratings during
laceration repair compared with the
control group (42).
Route
and dose of administration
In general, severe pain usually requires
intravenous analgesia, because this
provides the most rapid onset of pain
relief. Titration of intravenous opioids
remains the standard of care in treating
acute severe pain (43). Physicians often
use the wrong route of administration.
Intramuscular (IM) dosing versus
intravenous (IV) dosing is an example of
this. IV dosing allows the carers the
ability to appropriately titrate
medication for pain relief with a fairly
rapid onset of action. IM dosing not
only limits the physicians' ability to
titrate, but the onset of action is
longer than IV and may further be
limited by any underlying pathologic
state that is associated with decreased
perfusion. In addition, IM injections
are painful (24).
Since all opioids are lipophilic, it may
be reasonable to administer opioids
subcutaneously in patients who do not
have IV access. Subcutaneous
administration of opioids offers several
advantages over intramuscular
administration, such as less pain with
injection, more predictable effects,
fewer deep tissue complications (44,45).
The equivalent doses of all opioids are
based on the "gold standard" of 10 mg of
parenteral morphine (44-48). Among the
most commonly used opioid derivatives,
the semi-synthetic compound -fentanyl-
is the most potent opioid with a potency
100 times that of morphine.
A common approach is to begin treating
severe pain with intravenous morphine
4-6 mg titrated every 8-10 minutes (49).
Subcutaneous morphine 10 mg titrated
every 30 minutes can be used in patients
lacking IV access. Dosing adjustments
should be made downward in the elderly
or those with precarious underlying
medical conditions.
Physicians often
underdose or fail to give analgesic
drugs in the right frequency (24). A
general principle of pain management is
that smaller doses of analgesics are
required to prevent pain than to treat
pain. Analgesics are optimally
administered at short fixed intervals
before pain recurs (46).
Oligoanalgesia
and patient satisfaction
In a survey of 68 ED
fast-track patients, Blank, et al.,
detected inadequate pain relief as
indicated by higher discharge pain
scores than they were willing to
accept(20). Surprisingly, the authors
stressed that this finding did not
preclude patient satisfaction rating for
overall care as "very good". They
concluded that healthcare providers
should not rely on patient satisfaction
ratings as surrogate markers for the
quality of pain management. Reports
published in the last decade pointed out
that high patient satisfaction could
accompany minimal pain reduction(50,51).
It is possible that satisfaction from
other factors such as expertise and
kindness of staff, correctness of
diagnoses and appropriate treatment
could seem more important than
mismanagement of pain.
Conclusion
Pain management is not a simple task.
Decisions regarding administration of
pain medications are impaired by a full
range of biases, e.g. based on age,
gender and ethnicity. Concerns of
addiction, inadequacy of education with
respect to opioids and other analgesics
also contribute to the treatment
failure.
Patients' evaluation of pain should be
the sole reference point when deciding
whether to administer analgesics or not.
The patients' own characteristics should
help tailor the analgesic treatment.
Dose and route of the therapeutics
should be adjusted to the individual
requirements, but i.v. administration is
often the best choice.
The American College of Emergency
Physicians recommend the following
principles regarding pain management in
ED patients: (1) ED patients should
receive expeditious pain management,
avoiding delays such as those related to
diagnostic testing or consultation,(2)
Hospitals should develop unique
strategies that will optimize ED patient
pain management using both narcotic and
non-narcotic medications,(3) ED policies
and procedures should support the safe
utilization and prescription writing of
pain medication in the ED, (4) Effective
physician and patient educational
strategies should be developed regarding
pain, including the use of pain therapy
adjuncts and how to minimize pain after
disposition from the ED and;(5) Ongoing
research in the area of ED patient pain
management should be conducted.
Acute pain conditions are underevaluated
and undertreated in EDs, suggesting that
ED staff need more education about the
management of acute pain. The goal of
therapy is to provide enough analgesic
to relieve the patient's pain, using
techniques that minimize undesirable
side effects and provide prompt relief.
References
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