One of the first studies reporting oligoanalgesia in the ED was a retrospective chart review by Wilson and Pendleton in 1989. 1 They reviewed 198 patients admitted 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 regarding the degree of pain each patient was experiencing. Overall, 44% of patients received narcotic medication while in the ED, 60% received intramuscular (IM) doses. One-third of patients with documented severe or moderately severe pain received sub-optimal dosing of opioids; 69% of patients waited more than one hour for pain medication and 42% waited more than 2 hours. Thus, several problems were noted: pain assessment was lacking, suboptimal use and dosing of opioids existed, and patients experienced a delay in receiving pain medication.
Lewis et al in 1994, performed a retrospective review of ED acute fracture management from 8 hospitals; they found that oligoanalgesia was ubiquitous with no difference between urban versus suburban or teaching versus non-teaching hospitals. Only 30% of patients received analgesics during their ED visits. Neither fracture location nor patient age were found to significantly impact the decision to provide analgesia. This study has limitations in that its design was retrospective and pain scales were not used. Though it could be argued that those patients who did not receive pain medication were not experiencing significant pain, this study contributed to a growing body of evidence that physicians were failing to meet the analgesic needs of their patients.
Patients with fractures were twice as likely to get pain medication as patients without fractures, even when the level of reported pain was match controlled. 8 This represents a bias that sprains are not as painful as fractures. Ducharme and Barber in 1995, performed a prospective blinded study on ED pain assessment and therapy. 9 They described a lack of use of an objective scale or documentation of patient impression of pain, and a less than 25% rate of “intervention or medication” for pain. Similarly, in 1999, Tanabe and Buschmann documented only a 15% use of opioids in a prospective study on pain in the ED. 10 In 2002, Singer and Thode reported that half of patients with burns did not receive analgesia while in the ED, and almost half of the patients did not have their pain severity assessed. 11 It is apparent that oligoanalgesia and lack of pain assessment go hand in hand. It can be concluded that, if clinicians do not ask patients about their pain, it is unlikely that pain medications will be provided.
A prospective study by Kozlowski et al looking at analgesic use found that patients with isolated lower limb fractures seen by physicians were three times more likely to receive analgesia than those seen by physician assistants.8 This was a single institution study and the difference found in prescribing patterns between physicians and PAs cannot necessarily be extrapolated to other practice environments. Todd et al in 2003, designed a study to assess pain etiologies, patient pain experiences, pain management strategies, and patient satisfaction using a questionnaire and a chart review. Only 50% of patients received an analgesic, including 63% of patients reporting severe pain. Despite 69% of patients reporting that ED staff discussed the importance of pain management with them, 88% of those patients who did not receive pain medication did not ask for analgesia. This may be due to a lack of expectation on the part of the patient for pain control.
Forty-eight percent of patients were in moderate or severe pain at discharge, yet the majority of patients were either satisfied or very satisfied with their pain management. 5 These findings are surprising and may highlight the fact that patients have low expectations for pain control versus some other undetermined factors. In the study by Ducharme and Barber previously described, patient satisfaction was high despite a very low rate of pain intervention. 9
Oligoanalgesia in the elderly merits special mention because emergency physicians have self reported discomfort in managing this group. 12 13 Elderly patients with hip fractures are less likely than their younger counterparts with fractures to receive analgesia, 14 and patients with dementia have been reported to receive analgesia at rates below 25%, even when reporting pain. 15, 16 At the other end of the spectrum, neonates and young children with pain are also often undertreated for a variety of reasons, including barriers to communication. In one observational study of pediatric patients with a limb fracture, no patient was discharged with a prescription for pain medication. 17 Complicating communication barriers between children and physicians is the observation that parents may also underestimate clinically significant pain in their children; this is accentuated if the child has a cognitive impairment.18 19 When the cognitive impairment is severe, the parents tend to appreciate the child’s pain. However, when the cognitive impairment is mild, parents tend to believe their children are overreacting to painful stimuli. 19 Without the parents’ advocacy for their child’s pain, physicians are at an even greater disadvantage when addressing pain control.
It is clear that the concept of oligoanalgesia is supported by the literature. It is present across all patient populations. Knowledge of this makes it imperative to design and develop strategies to improve our management of pain. Using pain scales that allow patients to rate their pain is an important first step.