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Pain Management: Opportunities for Improvement Using the Internet

Schiller, Andrew MD; Fink, Glenn MD

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Dr. Schiller is the associate director of patient care services in the department of emergency medicine at St. Barnabas Medical Center, and involved with development of electronic medical records and online clinical decision support for Emergency Medical Associates, also in Livingston.

Dr. Fink is an emergency physician at St. Barnabas Medical Center in Livingston, NJ, and member of the board of Choice Media.

As so many emergency physicians know, pain is the fifth vital sign. Patients arrive in our departments in acute pain, and we are treating it early and aggressively. We also are seeing more patients with chronic pain who are on high opioid doses often prescribed by our increasingly abundant pain specialist colleagues. Every few minutes, the emergency physician needs to make a decision on how to treat pain. And every day we are held up to a patient satisfaction microscope, which in many ways is focused on our ability to treat pain. Can the Internet help us become more facile in treating and understanding pain?

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One of the biggest problems with pain management in the emergency department is oligoanalgesia — our patients are still not getting enough pain medication, and that is why regulatory bodies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) are scrutinizing that part of our practice. Developing a better awareness of acute and chronic pain syndromes and the newest treatments is now absolutely essential.

Acute pain (eudynia) is a normal response to noxious stimuli or acute internal pathology, which tends to protect the person from further insult. Chronic or maladaptive pain (maldynia) evolves into a syndrome where the pain itself becomes a disorder. Emergency physicians have started to take the lead in dealing with acute pain, but when confronted with patients suffering from chronic pain, our frustration reflects our lagging knowledge of chronic pain syndromes. We can reduce our frustration and our patient's frustration by increasing our knowledge of chronic pain, by working with our local pain management specialists, and by referring our chronic pain patients to Internet sites that provide useful information and peer support. With proper treatment, many chronic pain patients can move from patient status to productive people status.

One place to start is the article, “Eleven Common Myths about Pain Control,” by Robert Dachs, MD, at www.emedmag.com/html/pre/fea/features/121501.asp. From this article, emergency physicians can scrutinize their own prescribing practices and stop prescribing medications that just don't work. For a one-hour educational module on the treatment of acute pain, go to www.tuftspainmanagement.org. This Tufts site will soon have additional educational modules covering arthritis and low back pain.

The American Pain Society (www.ampainsoc.org) is a professional organization that advances pain-related research and practice. Their links will take you to the many professional organizations with pain-related concerns and activity.

The emergency physician who still has opioid phobia may want to visit the American Society of Addiction Medicine site, www.asam.org, and specifically its policy page explaining the difference between addiction, tolerance, and physical dependence at http://asam.org/pain/definitions2.pdf.

There are many sites created by pain specialists, and the National Pain Education Council at www.npecweb.org has some useful features. These include a toolbox with prescribing information and an equianalgesic chart. This site requires registration, and the main tools are pdf files, which slows it down. For Epocrates users, there is a “Narcotic Equivalents” equianalgesic file in the tables section.

At the Beth Israel Department of Pain and Palliative Care site, StopPain.org, click on “Professionals,” and you will find excellent slide shows on the pharmacotherapy of pain, back pain, neuropathic pain, and headache.

EPs' ability to treat pain is held up daily to a patient satisfaction microscope

RSD (reflex sympathetic dystrophy) is a good example of a chronic pain syndrome that can be vexing for the emergency physician. Learn about it at eMedicine.com's article at www.emedicine.com/emerg/topic497.htm.

By educating our chronic pain patients, they may be able to deal with their illness better, resulting in fewer ED visits. Those who can edit discharge instructions may want to include some excellent patient support and education web sites. For migraineurs, steer them to www.migraines.org. For the trigeminal neuralgia patients, try www.tna-support.org. Headache patients who are frequent ED visitors also can get forms to give to their neurologists or pain specialists for presentation on each ED visit. For these, refer your headache patients to the National Headache Foundation site, www.headaches.org/professional/educationindex.html. The ED forms are on the lower left portion of the page.

The International Pelvic Pain Society (www.pelvicpain.org) is a well presented site with information useful for professionals and patients. The site's “Approach to the Patient with Chronic Pelvic Pain” is substantial. Although emergency clinicians will not be involved with the detailed work-up of pelvic pain, knowledge of the differential will result in informed discussions with the patients regarding possible avenues to be explored after an ED visit. The site contains detailed information regarding endoscopy, the pelvic pain syndrome, vulvodynia, pelvic congestion, interstitial cystitis, endometriosis, mononeuropathy and nerve entrapment, and fibromyalgia.

The American Pain Foundation (painfoundation.org) is a “people's” pain page. It is designed to educate people with pain. It also serves as a focal point for promoting better care of pain patients. Patients referred to this site from the ED can obtain copies of the Pain Notebook to better document their pain and what helps or aggravates it. Visitors also can download the Pain Care Bill of Rights.

This site contains the largest collection of pain-related links of the sites we reviewed. PainAid is a section of the site with scheduled chat sessions, threaded discussion boards, and an ask-the-expert feature. The gathering of people with similar concerns and problems who might otherwise remain isolated is one of the continuing benefits of the Internet. ED discharge instructions are a great way to introduce your patient to these communities.

Emergency physicians, who spend a good part of their day relieving pain and suffering, sometimes find themselves in a professionally awkward situation: frustration with their interactions with chronic pain patients. An increasing familiarity with the adequate treatment of acute pain and chronic pain syndromes creates a more empathic physician and ultimately greater physician and patient satisfaction.

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Internet Sites on Pain Management

Eleven Common Myths about Pain Control

www.emedmag.com/html/pre/fea/features/121501.asp This article helps EPs scrutinize their prescribing practices and stop prescribing medications that don't work.

Educational Module on Acute Pain Treatment

www.tuftspainmanagement.org This site will soon add modules on arthritis and low back pain.

American Pain Society

www.ampainsoc.org APS advances pain-related research and practice, and the site has links to many professional organizations with pain-related activity.

American Society of Addiction Medicine

www.asam.org The policy page, at http://asam.org/pain/definitions2.pdf, explains the difference between addiction, tolerance, and physical dependence.

National Pain Education Council

www.npecweb.org This site includes a toolbox with prescribing information and an equianalgesic chart.

Beth Israel Department of Pain and Palliative Care

StopPain.org Valuable slide shows on the pharmacotherapy of pain, back pain, neuropathic pain, and headache.

EMedicine.com The site has an article on reflex sympathetic dystrophy at www.emedicine.com/emerg/topic497.htm.

International Pelvic Pain Society

www.pelvicpain.org Has substantial information on treating patients with chronic pelvic pain as well as detailed information on endoscopy, pelvic pain syndrome, vulvodynia, pelvic congestion, interstitial cystitis, endometriosis, mononeuropathy and nerve entrapment, and fibromyalgia.

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Sites for Patients

For migraineurs: www.migraines.org.

For trigeminal neuralgia patients: www.tna-support.org.

For headache patients: National Headache Foundation, www.headaches.org/professional/educationindex.html

For educating patients: American Pain Foundation, painfoundation.org. Here patients can obtain copies the Pain Notebook and the Pain Care Bill of Rights.

© 2004 Lippincott Williams & Wilkins, Inc.

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