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<< Pain Management in the Emergency Department

Disposition

Emergency physicians are well attuned to the need to  make a diagnosis whenever possible, the need to arrange for admission or follow-up, and the need to inform and educate the patient. Concurrent with these familiar necessities, emergency physicians must also consider whether or not the patient’s pain has been adequately controlled and develop a strategy for pain management if the patient is discharged home.

McIntosh and Leffler looked at the management of pain after ED discharge for common acute orthopedic injuries. A telephone questionnaire was done seven to 14 days after discharge. Patients were questioned about the type of medication received or prescribed from the ED, the filling of prescriptions, side effects of medications, interventions by other health care professionals, and the adequacy of pain relief in the ED and after discharge. Additionally, they were questioned regarding the operation of vehicles while taking their prescribed medications. Seventeen percent of patients did not fill their prescriptions; onehalf of non-steroidal anti-inflammatory drug prescriptions were not filled; 7% of patients drove while taking their medications. This study reports a high level of satisfaction with pain control, with 67% to 92% of patients describing their pain control as adequate.

The least satisfied were those patients who did not fill their prescriptions, while those who were most satisfied were discharged with a “starter pack” of 5 tablets of acetaminophen/oxycodone.145 Not all patients leave the ED satisfied: Johnson et al reported that the majority of patients presenting with pain leave the ED with “unresolved or worse pain.” 21 The discrepancy between Johnson’s study and McIntosh’s most likely is due to the type of pain studied and highlights the need for developing appropriate pain management discharge strategies including follow-up.

Re-assessment of pain should occur at discharge. Keep in mind that there might be an early pain free period with acute injury and that a patient who initially was fine, may subsequently benefit from an analgesic. It is best to write a prescription for a pain medication even if the patient is not experiencing pain, as it will likely be needed later. NSAIDs, when combined with aspirin or alcohol, may predispose to peptic ulcer disease (PUD) and should only be used in certain patients with caution. 146 If patients are not already on prophylaxis for PUD, it should be considered when using NSAIDs. 147 Although renal function is not always checked in the ED before prescribing NSAIDs, prostaglandin inhibition decreases vascular flow to the kidney and the glomerular filtration rate (GFR). 147 Baseline renal function should be considered for elderly patients, especially if a high or standing dose of NSAIDs is being considered. 148

Authors have suggested NSAIDs only be used with caution in asthmatics and in patients taking angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), or diuretics, since they may already have compromise to their renal function. The suggestion is not based on interaction between the medications but on limiting the iatrogenic insult to renal function. 147, 149 Acetaminophen, previously mentioned in thediscussion of elderly patients, as a drug of choice for  treatment of mild pain in the elderly population has a low side effect profile. However, at high doses, acetaminophen can cause an elevation in the international normalized ratio (INR) in those patients taking coumadin. Hylek et al found that patients taking coumadin had a ten-fold increase in their risk for supratherapeutic INR when taking over 9100 mg/week of acetaminophen. 150 When patients are discharged with acetaminophen, discharge instructions should include close follow-up with a recheck of their INR. Additionally, should a patient be discharged on an opiate/acetaminophen combination, education regarding the avoidance of additional acetaminophen products should occur.

Opiates can be effective for treating moderate to severe pain, but complications should be considered and anticipated. Constipation is a frequent side effect. A bowel regimen should be initiated when analgesics are prescribed, including: adequate fluid intake, exercise, and consideration of an osmotic, stimulant, or motility agent in some patients. Patients should be instructed to avoid bulking agents. In discharge instructions, patients should be advised of potential constipation and encouraged to seek follow-up evaluation. Patients should also be cautioned not to drive while taking narcotics, and warned about the risk of falls. Additionally, medication- induced pruritis can be treated with an anti-histamine and nausea with an anti-emetic agent. 148

In geriatric patients, pain should be evaluated in the context of their overall physical functioning. 74 Patients may already have a compromised ability in their activities of daily living and may be more severely restricted by painful conditions. Patients who previously lived independently may not be able to care for themselves effectively nor safely with new painful symptoms. Involvement of family members or social workers may be necessary to facilitate the discharge of an elderly patient. It is also important to understand that pain is not only undertreated in the ED, but oligoanalgesia is ubiquitous in the medical community. When discharging an elderly patient back to a nursing facility, a multidisciplinary assessment and management approach should be encouraged. 74 While such assessments are outside of the typical practice in the ED, it can be an important recommendation on discharge paperwork.

It is important to treat a patient’s pain, relying on their self-report and erring on the side of pain relief. However, it becomes apparent over time with certain patients that their visits are highly suspicious for drug-seeking behavior. This can become obvious when a patient has multiple visits for either multiple different painful conditions or multiple visits for the same complaint. Some EDs keep a file on “frequent fliers” or have a system for posting special concerns. Red flags can also include documentation of calls from a pharmacy to confirm prescriptions, calling to light that a patient may be filling prescriptions from multiple physicians. In these cases, discharge time may be the best time to notify the patient that the ED is best used to manage patients with acute pain and that further management of their chronic pain is best managed by a pain specialist. A referral to a pain center for further follow-up is recommended.