Pain Management in the Emergency Department
James R. Miner
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[6]: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.
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
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 | |
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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 Opioid Abuse in the Emergency Department
ED personnel commonly identify patients who they feel are attempting to obtain opioids for illegitimate purposes. Although drug addiction occurs in all patient populations, it is likely that the ED sees a higher proportion of such patients than a typical office-based practice. Unfortunately, the true prevalence of addiction and aberrant drug-seeking behaviors in the ED is unknown and difficult to measure.37 When the prevalence of such problems is overestimated, oligoanalgesia is the predictable result.
Definitions
In discussing issues of chemical dependency and aberrant behaviors related to opioid use, a valid system of nomenclature is necessary for clear communication and measurement. Historically, the meaning of different terms has changed, particularly in light of the increased use of chronic opioid therapy for cancer and noncancer chronic pain conditions. In treating pain in this population of patients with chronic opioids, confusion over the concepts of physical dependence, tolerance, addiction, and pseudoaddiction may constitute a barrier to understanding and to appropriate treatment. These phenomena are discrete, and standard definitions may be helpful in caring for such patients. Currently accepted definitions of these include the following: Addiction is a primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. Physical dependence is a state of adaptation that often includes tolerance and is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. Tolerance is a state of
adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time. Pseudoaddiction is a term which has been used to describe patient behaviors, including drug-seeking behavior, that may occur when pain is undertreated. Patients with unrelieved pain may become focused on obtaining medications, may “clock watch,” and may otherwise seem inappropriately “drug seeking.” Even such behaviors as illicit drug use and deception can occur in the patient’s efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated; the use of the term pseudoaddiction has fallen out of favor, as it is difficult to discern between the patient who finally achieves adequate pain control and the rare, but worrisome, patient who initially presents with poorly controlled pain and subsequently reports improvement but is actually diverting the opioids prescribed for nonmedical use.
adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time. Pseudoaddiction is a term which has been used to describe patient behaviors, including drug-seeking behavior, that may occur when pain is undertreated. Patients with unrelieved pain may become focused on obtaining medications, may “clock watch,” and may otherwise seem inappropriately “drug seeking.” Even such behaviors as illicit drug use and deception can occur in the patient’s efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated; the use of the term pseudoaddiction has fallen out of favor, as it is difficult to discern between the patient who finally achieves adequate pain control and the rare, but worrisome, patient who initially presents with poorly controlled pain and subsequently reports improvement but is actually diverting the opioids prescribed for nonmedical use.
The term substance abuse is particularly problematic and resistant to precise definition. The American Psychiatric Association has defined substance abuse as a maladaptive pattern of drug use associated with some manifest harm to the user or others. Other groups using consensus methodology have defined abuse as any use considered to be outside of socially accepted norms. Determining the bounds of “socially accepted norms” within the broad range of social strata treated within any ED is a difficult task. Physicians may believe that they “know abuse when they see it,” and its identification may be influenced by subjective judgments that may or may not correspond to socially accepted norms for the index patient’s particular social group.38 Often, the term substance misuse is applied to behaviors that are not perceived as particularly extreme (e.g., taking opioid analgesics to relieve symptoms other than pain such as anxiety or boredom).
The difficulty in determining whether a given set of behaviors fall within accepted definitions of substance use, misuse, or abuse has important implications outside the clinical realm. Physicians may prescribe controlled substances for the treatment of pain, whereas patients may use these drugs to treat a broad range of symptoms with varying degrees of relatedness to underlying pain syndromes and may, in fact, use drugs in a manner totally unrelated to the physicians’ intent (i.e., to obtain euphoric, rather than analgesic, effects). Given the unclear distinctions between use, misuse, and abuse and a regulatory climate in which practitioners prescribing patterns are increasingly scrutinized, emergency physicians are required to be cautious when the need to prescribe opioids to patients with whom they expect to have only a transitory relationship.
Using any definition, substance abuse is a highly prevalent problem in the ED.11,39 The National Survey on Drug Use and Health reports that in 2015, an estimated 10.1%, of the population aged 12 years or older used an illicit drug during the month prior to the survey interview.40 Importantly, the survey documents a 13.6% reported lifetime nonmedical use of pain relievers in 2014. To be considered nonmedical use, the respondent had to take drugs not prescribed for them or take them only for the “experience or feeling” they caused. Specific analgesics included Vicodin, Lortab, or Lorcet (combination analgesics containing hydrocodone); Percocet, Percodan, or Tylox (combination analgesics containing oxycodone); hydrocodone; OxyContin (extended-release oxycodone); methadone; and tramadol.
In contrast to the prominence of ED-based data collection systems in efforts to monitor deleterious outcomes associated with substance abuse, relatively few studies have systematically assessed substance abuse prevalence and treatment needs in the ED population.41 As an example, the Drug Abuse Warning Network is a federally financed, public health surveillance system that monitors drug-related ED visits and drug-related deaths investigated by medical examiners and coroners. This reporting system involves hundreds of hospital EDs throughout the United States and provides valuable data with which to monitor drug abuse trends. In contrast to this large monitoring research enterprise, relatively little focus has been given to use of the ED as a setting in which to intervene in substance abuse problems.
In a study of trauma patients, Soderstrom et al.42 assessed the prevalence of psychoactive substance use disorders in a large, unselected group of seriously injured patients treated in one Baltimore ED, using standardized diagnostic interviews and explicit criteria. Psychoactive substance use disorders were diagnosed using the Structured Clinical Interview, an instrument based on the Diagnostic and Statistical Manual of Mental Disorders. Of 1,118 patients consenting to the study, 71.8% used alcohol, 45.3% used illegal drugs, 18.8% demonstrated active drug abuse or dependence, and 32.1% demonstrated concurrent alcohol abuse or dependence.43 The high rate of substance use and abuse among trauma patients, and the fact that trauma usually is associated with pain that requires treatment, complicates the treatment of pain from trauma.
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.
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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