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<< Pain Management in the Emergency Department

Epidemiology And Practice Patterns

Pain relief is the reason for 20% of doctor visits, yet only 0.6% of the National Institutes of Health’s (NIH) budget is devoted to basic and clinical pain research. 20 Studies on the prevalence of pain in the ED range from 52% to 78% of patients. 10, 21, 22 Given the ubiquity of pain complaints amongst patients presenting to the ED, physicians may perceive that drug-seeking behavior is more common than it actually is. One study in an ED seeing 75,000 visits per year, estimated that less than 0.5% of patients requesting 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 complaints. Chronic pain is an epidemic and poses a daily challenge for the practicing emergency physician. Indeed, EMTALA identifies pain as an emergent condition, however, it is unclear how to address those with a chronic condition; there is limited data on the epidemiology of acute conditions superimposed on chronic states. There are no studies that document the frequency of patients coming to the emergency department out of frustration due to inadequate pain control for a chronic condition. That said, 50% or more of the general population self-reports being in chronic pain. 25 Common etiologies of chronic pain include low back pain (40% of the population) 26 and migraine (15% of the population). 27 Patients with chronic conditions can have acute disease as well: patients with chronic low back pain can have an acute disc herniation, and patients with a history of migraine can develop a subarachnoid hemorrhage.

The Canadian Association of Emergency Physicians held a consensus conference on emergency pain management in 1993 and published the proceedings as a consensus paper in 1994. After an extensive literature review, one of their findings was that health care workers often “underestimate patient suffering.” 28 Since then, several studies have looked at this issue. In 1999, Singer et al prospectively assessed patient versus practitioner assessments of pain from commonly performed procedures and found that the correlation was poor to fair. This study highlighted the poor use of local anesthesia for common painful procedures such as nasogastric tubes and foley catheters. 29

In 2002, Guru and Dubinsky looked at patient versus caregiver perception of acute pain in the ED, as well as patient satisfaction. It was an observational, prospective study in which nurses, physicians, and patients rated pain levels using the VAS and NRS (see discussion of “pain scales” that follow). They found that nurse and physician ratings of pain were lower than the patient’s own rating of their pain. In this study, 68% of patients with severe pain received analgesic medication, with 49% of patients experiencing no pain relief. Interestingly, 50% of satisfied patients had no pain relief. There was no physician-documented objective pain scale and only one physician documented patient response to medication. 30 Eder at al evaluated documentation of patient pain by a retrospective chart review of 261 ED patients and found that, while the majority of charts contained an initial pain assessment, only 23% of charts used a pain scale. Response to therapy was noted on 39% of charts; however, again, pain scale use was low at 19%. Patients with severe pain on arrival, those with chest pain, and those who required “powerful analgesics” were more likely to receive a subsequent pain assessment. Nurses were 2.2 times more likely to document pain assessments after treatment than physicians. 31 As with the study by Guru and Dubinsky, this study calls to attention the need for reassessment of pain after intervention. It is possible that physicians are reassessing, but these studies show that documentation is lacking. Pain assessment scales give patients the opportunity to express the level of pain they are experiencing and, thus, play a crucial role in providing appropriate pain treatment. 30 Health care providers can become desensitized to a patient’s pain given the fact that the majority of patients seeking medical care in the ED have a pain-related complaint. Re-assessment allows the provider to remain aware of the patient’s level of pain. A pre-formatted chart with pain scales could facilitate re-evaluation and should be considered. 31