The specialties of both emergency medicine and pain medicine are relatively new members of the modern house of medicine. The first academic department of emergency medicine was established in 1971, and the American Board of Medical Specialties recognized emergency medicine as a distinct specialty by conferring primary board status only 30 years ago. The numbers of visits to US emergency departments (EDs) have increased markedly over the past decade. From 2005 to 2015, the annual ED visit volumes increased from 115.3 million to 136.3 million, a 20% increase following a similar increase in the previous decade.1
There are more than 34,000 active board-certified emergency physicians, 31,000 of whom are represented by the American College of Emergency Physicians (ACEP).
EDs provide care for patients with an extraordinarily broad range of illnesses and injuries associated with both acute and chronic pain. Pain is common in the ED, with up to 42% of ED visits being related to painful conditions.2
It is commonly believed that injury and trauma are responsible for the majority of ED visits associated with pain; however, this impression is misleading. A landmark multicenter study of adults presenting to EDs in the United States and Canada with moderate to severe pain found that two-thirds of patients presentation with pain from medical, rather than traumatic, conditions.3
Major categories of discharge diagnoses reported in this study appear in Figure 113.1
In the United States, the ED serves as a safety net for our fragmented health care system. Pain is but one of many conditions for which emergency physicians not only treat acute clinical presentations but also care for those with chronic or recurrent painful conditions who are unable to access other parts of the health care system. Emergency physicians also frequently manage pain in the course of performing emergent diagnostic and therapeutic procedures.
FIGURE 113.1 Major categories of discharge diagnoses among patients presenting to the emergency department (ED) with moderate to severe pain. Note: Other diagnoses present for 243 patients. URI, upper respiratory tract infection; UTI, urinary tract infection. (Data from Todd KH, Ducharme J, Choiniere M, et al. Pain in the emergency department: results of the Pain and Emergency Medicine Initiative (PEMI) multicenter study. J Pain 2007;8:460-466.)
This chapter discusses the prevalence of acute and chronic pain in the ED, its assessment, barriers to adequate pain treatment, the influence of substance use disorders and aberrant drug-related behaviors on ED pain practices, as well as a variety of commonly employed pain treatment and procedural sedation modalities. Space limits prohibit a discussion of the wide variety of specific painful conditions that present to the ED.
The Prevalence of Pain in the Emergency Department
Pain is the most frequent reason for seeking ED treatment, and as a part of the presenting complaint, pain accounts for over 70% of visits to US EDs.3,4,5
A study conducted by Tanabe and Buschmann,6
found that among adults treated at one Chicago ED, 78% presented with a chief complaint related to pain. Of these patients, only 47% received analgesics. For patients receiving analgesics, an average of 74 minutes elapsed from the time of arrival to the time of treatment.
Cordell et al.4
reported an analysis of secondary data from an urban, tertiary-care ED using explicit data abstraction rules to determine the prevalence of pain and to assign painful conditions
into standard categories. With inclusion of all age groups, they found evidence of pain in 61% of patients. Pain was the chief complaint for 52% of patient visits. After excluding patients less than 5 years of age for whom chart reviews are obviously less reliable, almost 70% of patient encounters involved pain complaints.
Although the high prevalence of pain among ED patients is well documented, the underlying conditions responsible for pain in this population are less well characterized. In Cordell et al.’s4
retrospective study, 11% of patients presenting to the ED were judged to be suffering from pain that was chronic in nature. In a larger prospective multicenter study conducted in the United States and Canada, 44% of ultimately discharged patients presenting to the ED with pain reported underlying chronic pain syndromes. In one-half of these cases, the ED visit was prompted by an exacerbation of this chronic pain condition. Importantly, patients with chronic pain reported three to four times the number of annual physician visits when compared to those without chronic pain. Median and mean durations of symptoms for those reporting chronic pain syndromes were 24 and 52 months, respectively.3
For physicians who view themselves as experts in the management of acute medical and surgical emergencies, chronic pain may represent a less familiar condition with which to contend.
EDs frequently treat patients with chronic or recurrent pain who are often frustrated by a lack of information about ongoing pain management and poor access to specialty-level care. In a 2007 study, 500 US adults with chronic or recurrent pain and an ED visit within the past 2 years were interviewed.7
Sixty percent were female, their median age was 54 years, two-thirds were under the care of a physician, and 14% were uninsured. They reported an average of 4.2 ED visits within the past 2 years. Relatively large proportions reported pain relief during the ED visit, and 57% endorsed that “the ED staff understood how to treat my pain” as “definitely true.” Although over three-fourths of patients felt receiving that additional information on pain management (82%) or referrals to specialists (74%) was “extremely” or “very” important, only one-half reported receiving such referrals (46%) or information (55%). A significant minority (11%) reported that the “ED staff made me feel like I was just seeking drugs.” The majority (55%) were “very” or “completely” satisfied with their medical treatment, whereas 24% were “neutral” to “completely” dissatisfied. In multivariate models, greater age, male gender, higher level of education, shorter waiting time, use of imaging, and pain relief contributed to patient satisfaction with ED care.
Findings from this survey provide a more precise estimate of the prevalence of ED use associated with chronic and recurrent pain in the United States. The final survey incidence rate of adults reporting a recent ED visit for chronic or recurrent pain was 15% of all those reached by phone. Given the US adult population of approximately 225 million, this survey incidence rate suggests that 34 million adults meet our criteria of an ED visit within the past 2 years for chronic or recurrent pain. Within this population, approximately 43%, or 15 million people, experience recurrent pain, whereas 57%, or 19 million people, have underlying chronic pain syndromes.
Pain management in the ED has received increased emphasis over the past two decades, including increased emphasis on patient satisfaction surveys, and The Joint Commission’s emphasis on analgesia.8
There have been a large number of important findings showing that analgesia in the ED is often inadequate, including an Institute of Medicine report,9
leading to emphasis on improving pain treatment. This emphasis has likely resulted in improvements in pain treatment in the ED but may have had the unintended consequence of increasing the use of opioids in the ED and after ED care.
The high prevalence of acute and chronic pain in the ED, and the increased emphasis on its treatment, has led to the question of the role of EDs in the increasing use of opioids in the United States.10,11
Among 20- to 29-year-olds, emergency medicine ranks third among specialties in terms of the number of opioid prescriptions, writing 12% of the total number of prescriptions.12
In one study, 17% of ED patients were discharged with an opioid medication, the majority of which were small pill counts and immediate-release formulations.13
A recent study found that for opioid-naive patients, the odds ratio for developing recurrent use after a single prescription for opioids versus a nonopioid prescription from the ED was 1.8.14
This is difficult to interpret because many of the patients who received an opioid may have had more pain or a more severe injury than those who did not, but it highlights the need for attention to the risk of recurrent opioid use when they are used. The risk of opioids from the ED on patients in the ED with chronic or recurrent pain who already use opioids is much likely larger but is difficult to quantify. This complicates pain treatment in the ED and makes it a difficult challenge for emergency physicians.15
The increase in deaths associated with opioid abuse has heightened concern16,17
and has led to the development of some actions to decrease the risk to patients. This includes the U.S. Food and Drug Administration’s proposal for the establishment of physician education programs for the prescribing of long-acting and extended-release opioids as part of the national opioid risk evaluation and mitigation strategy (REMS) program.18
Statewide opioid prescribing guidelines, such as those developed by the Utah Department of Health19
and the Washington Chapter of the ACEP,20
and guidelines developed by individual physician groups have shown promise in decreasing opioid prescription overdoses.21
ACEP has also developed a policy on the use of opioids that clarifies the use of state prescription monitoring programs, the treatment of back pain with opioids, and the use of different opioids.22
As research advances and policies develop, the role of EDs in opioid abuse will be further explored and the effects mitigated.
The Assessment of Pain in the Emergency Department
Pain is inherently subjective and inevitably complex. Patients experience pain and suffering as individuals; clinicians assess it only indirectly. The emergency provider’s task is to use a commonly understood vocabulary and classification system in assessing pain so that our findings can be communicated consistently. Only by quantifying the pain experience in meaningful ways can we move beyond practices that are influenced by myth and opinion toward a scientific approach to our many questions regarding the pain experience. This challenge is at the root of the difficulties in treating pain and not only in the ED; thus, issues surrounding pain assessment should have primacy in our attempts to understand our patients’ pain experiences.
EDs employ a number of practical unidimensional pain assessment tools. Viewing pain as the “fifth vital sign,” as encouraged by The Joint Commission on Accreditation of Health Care Organizations, has fostered the widespread use of such tools. For those without cognitive impairment, pain intensity is routinely assessed with either an 11-point numerical rating scale (NRS) or a graphical rating scale (GRS). The NRS is sensitive to the short-term changes in pain intensity associated with emergency care and is the most commonly employed pain assessment instrument. GRS or picture scales are particularly useful for populations with limited literacy, including children. The visual analog scale (VAS) is used by some EDs; however, this instrument is more commonly employed in research settings. There is no demonstrated advantage in using a VAS over an NRS in the ED setting; both are reliable and valid measures
of pain intensity. A patient’s answer to the query “Do you want more pain medication?” however, has been shown to be an unreliable measure of pain or relief, and descriptive pain scales are likely to prove more accurate and reliable.23
Among nonverbal patients, including infants or those with cognitive impairment and dementia, a number of observational pain scales are available for use. Both the Face, Legs, Activity, Cry, and Consolability (FLACC) observational scale for use in very young children24
and the Pain Assessment in Advanced Dementia scale for use in the setting of advanced dementia25
are used with some frequency in the ED; however, adequate observational pain assessments are less the exception than the rule.
No matter the specific pain scale used, assessments should be repeated after therapeutic interventions and at the time of ED discharge. One multicenter study found that relatively few ED patients are reassessed after an initial pain score, reporting that fewer than one-third of ED patients presenting with moderate to severe pain had repeat pain assessments while in the ED.3
Despite efforts to promote pain intensity as an outcome measure with which to judge the quality of ED pain practice, the finding that pain intensity is measured only once in most EDs may mirrors medicine’s traditional view of pain as a diagnostic indicator rather than an outcome deserving of attention in its own right.
Oligoanalgesia in the Emergency Department
Notwithstanding the clinician’s duty to provide compassionate care, pain that is not acknowledged and managed appropriately causes anxiety, depression, sleep disturbances, increased oxygen demands with the potential for end-organ ischemia, and decreased movement with an increased risk of venous thrombosis.26
Failure to recognize and treat pain may also result in dissatisfaction with medical care, hostility toward the physician, unscheduled returns to the ED, delayed complete return to full function, and, potentially, an increased risk of litigation.27
Although adequate analgesia in the ED would appear to be an important goal of treatment, the underuse of analgesics, termed “oligoanalgesia” by Wilson and Pendleton28
in 1989, occurs in a large proportion of ED patients. A variety of factors are felt to give rise to pain under treatment, and these are listed in Table 113.1
Emergency medicine investigators have identified a number of risk factors for oligoanalgesia, ranging from patient factors to physician variation.29
As in other settings, the very young or old tend to receive less intensive treatment for pain in ED. Studies have documented oligoanalgesia and delays to analgesic administration among those of minority ethnicity for a variety of painful conditions, even when objective evidence for the presence of pain is obvious (e.g., long-bone fractures).2,30,31,32,33
Although patients’ expectations for pain treatment and perceptions of pain intensity don’t differ by ethnic groups, when patients are matched for socioeconomic factors, differences have been noted in the manner in which patients of different cultural backgrounds express their pain. Differences in the interactions of physicians and patients of different ethnic groups have been described, and subtle differences within these interactions may affect the physician’s pain assessment.34
When affect, actual patient-physician interaction, and cultural expressions of ethnicity are removed from a case presentation, such as through written clinical vignettes, patients with similar pain tend to be similarly treated by physicians.35
Cultural discordance between the patient and the physician may hinder the ability of patients to confer an understanding of their pain to the physician.
TABLE 113.1 Factors Contributing to Emergency Department (ED) Oligoanalgesia
Lack of educational emphasis on pain management
Inadequate ED quality improvement systems
Lack of ED pain research, particularly among geriatric and pediatric populations
Emergency providers’ concerns regarding opioid addiction and abuse
Fear of opioid adverse effects
Racial and ethnic bias
Of course, any treatment of pain is dependent on the physician’s accurate assessment of the patient’s pain. In fact, the only predictor of treatment that Bartfield and colleagues36
found for ED patients with back pain was the physician’s assessment, regardless of the patients’ ethnicity, age, or insurance status. Disparities in the treatment of pain are more likely to result from variations in physicians’ assessment of pain intensity than variations in treatment among patients judged to have similar degrees of pain.
Although emergency physicians may be reluctant to accept a patient’s report as the most reliable indicator of pain, and disparities between patient’s and physician’s pain intensity ratings may lead to inadequately treated pain, even patients themselves may be reluctant to report the presence of pain and its intensity. This may be due to low expectations of obtaining pain relief, fear of analgesic side effects, and perhaps the notion that pain is to be expected as part of an underlying disease or from medical treatments. Some patients exhibit an inappropriate fear of addiction when prescribed opioids or fear the stigma associated with opioid use, even in the short term.
Pain and “Drug-Seeking Behavior” in the Emergency Department
The preceding discussion makes clear the high prevalence of both pain and substance use disorders in the ED. Although acute and chronic pains are far more common than substance use disorders, it is inevitable that emergency physicians will frequently encounter patients presenting with both pain and substance use disorders. Professional discussions of pain treatment in the ED frequently center on concerns of being duped by such patients who fabricate painful symptoms in order to obtain opioids, so-called “drug-seeking behavior.”34,37
Drug-seeking behaviors may represent an entirely appropriate response by those with chronic pain who are routinely undertreated by the medical profession and for who comprehensive pain treatment centers are in short supply. Although the term drug-seeking behavior
is poorly defined, it is used in the emergency medicine literature and will be used with acknowledgment of its imprecision.
Only a limited amount of emergency medicine research has addressed this problematic issue. In 1996, Zechnich and Hedges44
attempted to measure community-wide use of ED services by patients at high risk for drug-seeking behavior. In this retrospective, observational study, patients were categorized as exhibiting drug-seeking behavior if they sought care at a university hospital in Portland, Oregon, for a specific pain-related diagnosis (i.e., ureteral colic, toothache, back pain, abdominal pain, or headache) and were either independently identified on at least one other local hospital’s “patient alert” list or suffered a drug-related death during the year in question. After identifying 33 such patients, they determined the frequency of their ED visits at each of seven local hospitals and conducted detailed chart reviews of their visits at three of these hospitals. The patients identified as drug seeking were generally young, and one-half of drug seekers were female. This suggests that drug-seeking behaviors are exhibited (or identified) more commonly among female ED patients with substance abuse problems than among males.39,45
The 33 patients visited EDs, urgent care clinics, or were hospitalized a total of 379 times over the study period, for an average of 12.6 visits per person annually. Interestingly, although chart reviews identified 17 patients who were told that he or she “would receive no further narcotics” at a given facility, these patients subsequently received controlled substances from another hospital in 93% of cases and from even the same facility in 71%. The authors suggested that information sharing between hospitals could help to identify drug-seeking patients
and promote more consistent community-wide care and appropriate substance abuse interventions.
The need for information sharing has led to the development of statewide prescription monitoring programs.46
These programs allow physicians to determine whether a patient has received opioid medications regardless of their individual report, allowing easier identification of patients who are misrepresenting their current opioid use. Such monitoring systems are generally not required and are not universal, but data indicate they are successful, at least more so than the previous attempts at internal lists many EDs had used, and their use should be expanded.47
It has been shown that the use of such lists alters physicians’ prescribing behavior, both by increasing pain medications for patients who do not exhibit frequent use and identifying patients at risk for opioid abuse or dependence related to their treatment.48,49
Although early versions of these monitoring programs were difficult to access and use, they are becoming increasing usable and are becoming a typically step in the prescribing of opioids in the ED.50
Prescription drug monitoring programs are generally underused in EDs, and nationwide enrollment is low among emergency physicians. In order to improve this, an expert panel was convened by ACEP and made policy recommendations within these main themes: Enrollment should be mandatory, with an automatic process to mitigate the workload; registration should be open to all prescribers; delegates should have access to prescription drug monitoring program to alleviate workflow burdens; prescription drug monitoring program data should be pushed into hospital electronic health records; prescription drug monitoring program review should be mandatory for patients receiving opioid prescriptions and based on objective criteria; the prescription drug monitoring program content should be standardized and updated in a timely manner; and states should encourage interstate data sharing.51
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