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Charting a Course to Pain Relief

Sorelle, Ruth MPH

Special Report

It is ubiquitous — in the waiting areas, treatment cubicles, and trauma rooms. Pain is the overwhelming force that drives at least 70 percent of patients to seek emergency treatment, and yet, most emergency physicians will admit it is often undertreated.

It has bothered Knox Todd, MD, MPH, an associate professor at Emory University School of Medicine, to the point that he plans to devote the next few years to studying pain and how to ensure that it is adequately managed in the emergency department. He wants to see a plan that will map the road to that goal. Such a plan is necessary, he said, because “if you have no destination, any road will do.”

One problem, he said, is not having patient-oriented outcomes to use in pain research. “Now we look at pain intensity and patient satisfaction. They don't nearly approximate the patient experience,” he said. The problem is that emergency departments do not approach the issue of pain relief in an organized fashion.



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Chief Complaint

William H. Cordell, MD, the director of research in the department of emergency medicine at Indiana University School of Medicine, said he and his colleagues evaluated the notion that pain is the number one complaint in the emergency department by evaluating seven consecutive days of patient charts, a total of 1,665 (Acad Emerg Med [abstract] 2001; 8(5):428). Pain was defined as the word “pain” or an equivalent such as “aching,” “burning,” or “discomfort” recorded on the chart.

His study presented at the Society of Academic Emergency Medicine annual meeting in May showed that 61.2 percent of patients who complained of pain had that documented on the chart. Of the 1,019 with pain, it was the chief complaint in 869 or 85.4 percent.

The study was conservative because “we included patients who couldn't talk, people who were intubated, and the critically ill,” he said. Although this study does not confirm that pain is the number one complaint, it does have a high prevalence in the emergency department, said Dr. Cordell.

“The implication of this is twofold,” he said. “One is you need to devote more education to both physicians and nurses about what pain is and how pain is monitored, measured, and treated. If it is that common, we should be darned good at this.

“The second implication is that familiarity breeds contempt or [pain is] so much part of the background noise that it gets overlooked. Is it trivialized by familiarity? The flip side of that is that emergency physicians and nurses are leaders in pain treatment. We need to be role models for our own specialty and also for other specialties in how we effectively manage pain.”

Ensuring that physicians treat pain adequately will require more education about pain management, Dr. Cordell said. Most medical schools provide less than five hours of didactics in pain management, he said, and most knowledge and habits in pain control come from role modeling, often using models that are not sensitive to patient needs.

“We have to attack this two ways,” he said. “We've got to develop strong role models. That is where emergency medicine is prime material. We see pain as highly prevalent in our practice. It's there every day. We have to get to doctors and nurses early in their education, and develop a model curriculum that hits in the freshman year and then builds on that framework of effective pain control.

Emergency medicine also has to develop “team learning” principles, he said. “A year ago, we developed a model curriculum, and all the nurses and doctors went through it with the idea of ‘let's change our attitudes and knowledge about pain,'” he said. Pain control is a tripartite effort that includes doctors, nurses, and patients, he noted.

Patients are at times their own worse enemies because they fear the effects of appropriate and effective drugs, Dr. Cordell said. “I hear it all the time, ‘I don't want to get addicted.’ Giving opioids to a grandmother in pain is not going to addict her. Her biggest problem is likely to be constipation. We can treat that.”

The current pain research does not use patient-oriented outcomes, looking only at pain intensity and patient satisfaction

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Quick Relief

Treating pain adequately, however, means getting analgesia to patients quickly, said David Fosnocht, MD, an assistant professor in the division of emergency medicine at the University of Utah in Salt Lake City (Acad Emerg Med [abstract] 2001;8(5):484).

In their study also presented at the SAEM annual meeting, he and his colleagues found that patients' expectations of when their pain would be relieved in the emergency department were far less than what actually happened.

In the prospective, observational study, Dr. Fosnocht and his colleagues evaluated the care of patients who sought care in their emergency department between September and December 1999. Seven hundred seventy-five of the patient surveys were used in the analysis. Patients said on average that they thought 22 minutes was a reasonable time to wait for pain medication. However, pain medicines were actually given 79 minutes after the patient's arrival. Only 305 of the 757 patients (40%) received pain medication. Patients who were in pain because of isolated extremity injuries received pain medication in 60 minutes while those with abdominal pain waited 110 minutes.

Dr. Fosnocht said he was not surprised by what he found. “One thing that was a little surprising was that the patients are not unreasonable in their expectation of how quickly it takes to get pain medications delivered. They don't come in saying they expect pain medicines at minute zero,” he said. “We are quite far off in terms of how quickly we actually do it.”

“What we found was that we don't give pain medications to the majority of our patients,” he said. “The patients who got medications at 79 minutes represented only 40 percent of patients who presented with pain.

“We are trying to figure … out [why]. In part, it is the environment in which we work. We often get distracted by making diagnoses and treating the conditions that are causing the pain. But we don't address the pain, which may be the reason patients come to the emergency department to begin with. The environment we work in is busy and chaotic, and pain medications have not been a high priority for us.

“Nurses and physicians are poor judges of patients' pain,” he said. “We tend to underestimate the degree of pain patients are in compared to what they self-report. Over time, we get numb to complaints. It is important to raise the visibility of pain as an important patient issue,” he said.

Another problem is the misconception that patients are demonstrating drugseeking behavior, he said. “The literature shows that the number of people who are drug-seeking is exceedingly small — less than one percent,” Dr. Fosnocht said. “It's a perception we have to be on guard against. It tends to color our perceptions of someone asking for pain medication.”

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Cultural Misperceptions

Ethnicity and cultural misperceptions also can affect physicians' willingness to effectively control patients' pain, Dr. Fosnocht said. “Several studies have looked at the cultural aspects of pain medication, and found that patients with different ethnic backgrounds have their pain treated less commonly than the majority of patients in the emergency department,” he said.

Yet, he said, patients of different ethnic backgrounds have the same expectations of pain relief as the majority of patients in the emergency department. “The reason they don't get pain medications may be more due to our perceptions than theirs,” he said.

“As we look at how severe pain was when patients came in, we found that patients with more severe pain were more likely to be treated,” he said. “Those who rated their pain as mild to moderate were less likely to be treated.” Educating patients to express their needs as well as the staff to ask about pain and to respond will help ensure that “we can treat pain more effectively,” said Dr. Fosnocht.

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The Effects of Medication

Understanding the effects of pain medication on different kinds of patients will help ensure that patients get adequate analgesia, said Penny Miller, RN, MS, a nurse practitioner who is an emergency instructor at the University of California at Davis in Sacramento.

She and a colleague evaluated the effect of opioids on men and women when they are used in the emergency department (Acad Emerg Med [abstract] 2001;8(5):430). In the prospective, double-blind trial, she and her colleague randomized patients over age 18 with significant pain to receive either 10 mg morphine in two doses or 2 mg butorphanol in two doses. Visual analog pain scores were obtained at baseline, 30 minutes, 60 minutes, and 120 minutes. Morphine was described as the prototype opioid associated with the mu receptor, and butorphanol was the one associated with the kappa opioid.

The research currently looks only “at pain intensity and patient satisfaction. They don't nearly approximate the patient experience.”

Dr. Knox Todd

EPs “need to devote more education to both physicians and nurses about what pain is and how pain is monitored, measured, and treated. If it is that common, we should be darned good at this.”

Dr. William Cordell

“I wish we had more flexibility in dosing.”

Ms. Penny Miller

“One thing that was a little surprising was that the patients are not unreasonable in their expectation of how quickly it takes to get pain medications delivered. They don't come in saying they expect pain medicines at minute zero.”

Dr. David Fosnocht

“If we simplify our [pain] scale and make it broadly applicable, it might help achieve our objective to stay focused on pain and the documentation of its treatment.”

Dr. Ed Sloan

Of the 94 subjects in the study, 49 were men and 45 were women whose pain was about the same at the initial pain scores. At 30 minutes, there was no difference, but at 60 minutes, women who had received butorphanol had significantly lower scores than those who had received morphine. At 120 minutes, pain scores evened out.

Ms. Miller, whose interest in pain management dates back to her days on a burn unit, said the results may have occurred because of low doses given patients. “After working through our study, I wish we had more flexibility in dosing,” she said.

She said she would like to see more studies comparing different kinds of pain relief medication because it would change the way people view such medicines. “You need to recognize that if you give someone the first dose of morphine and it is not working, you might try something different,” Ms. Miller said. “There are many, many drugs available to us.”

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Documenting pain management will help doctors and nurses understand when they have managed to relieve pain and when they have failed. In a study at the University of Illinois at Chicago, Steve Eder, MPH, a first-year medical student worked with Ed Sloan, MD, a member of the faculty, and Dr. Todd of Emory to evaluate the documentation of pain in the emergency department. (Acad Emerg Med [abstract] 2001;8(5):427).

The study concluded that nurses and doctors in the emergency department will have to be more systematic about their documentation of pain before, during, and after treatment if they are to comply with guidelines from the Joint Commission on Accreditation of Healthcare Organizations. In the study, patients were prospectively surveyed after discharge from the emergency department about the management of their pain during their visit. The documentation of pain by nurses and doctors was retrospectively reviewed to determine if they were in compliance with JCAHO rues.

Of the 261 charts available for review, some type of initial pain assessment was noted on 95 percent. A pain scale was initially used only on the charts of 22 percent of patients. After treatment and discharge, documentation of pain was noted for only 35 percent and eight percent of patients respectively. The pain scale was used in only 14 percent and four percent of patients at those time points.

Although nurses were more likely than physicians to document pain at the initial point, they were more likely to document pain assessments subsequently. At the end of the emergency department stay, he said, more than 55 percent of patients said they were still in moderate to severe pain.

Dr. Sloan, a faculty member at the school, said one thing the study indicated is that there is a need for a consensus on how to record pain in the emergency department. “A pain scale, although precise for research, might not be the best tool to use broadly with patients across many settings. As a clinician, if you said a patient's pain was mild, moderate, or severe, I would have an idea. Patients would understand if you asked that. If we simplify our scale and make it broadly applicable, it might help achieve our objective to stay focused on pain and the documentation of its treatment.”

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Pain Undertreatment

In the final analysis, it is the non-treatment or undertreatment of pain that is the current focus. A study presented at the SAEM annual meeting by Thomas D. Wendel, MD, an Albert Einstein University School of Medicine emergency medicine department faculty member, found that demographics, the reason for the patient's visit, the level of pain, tests, treatment disposition, and hospital type and location all affect a patient's risk of oligoanalgesia or pain undertreatment (Acad Emerg Med [abstract] 2001; 8(5):427-b).

Using the National Hospital Ambulatory Medical Care Survey '97, he obtained information on 22,209 emergency department visits. In this study, he defined undertreatment of pain as a patient's having mild to moderate pain and receiving no analgesia or a patient with severe pain not receiving opioid medication. Painful condition is defined as any complaint of pain, fracture/dislocation, ache, or burn.

Dr. Wendel said a common comment from providers is that they are hesitant to ask about patients' pain because they think everyone will complain about severe pain. Yet, he said, that is not true. Another myth is that pain in some conditions, such as abdominal problems and headaches, should not be treated. Yet, he said, the literature indicates that there is no condition where pain should not be treated.

They say that patients who complain about pain are hysterical and that patients who do not complain don't have any, said Dr. Wendel. Patients who were sickest, whose care was labeled urgent, or those who were admitted were more likely to be undertreated, he said. The oldest patients are at most risk for being undertreated, he said. There are even geographical differences in pain treatment, he said.

Dr. Todd is convinced that adequate treatment of pain will come when the profession itself reacts to the need. “I have been impressed with the lack of impact JCAHO has had. The JCAHO requirements concentrate on assessment, but the literature has shown no positive benefit on patient experience or physician practice. They are not sufficient to change practice.”

“It all goes back to education,” Dr. Todd said. In the future, he said, he hopes that physicians will come to recognize pain and to treat it adequately. He said, though, that patients will have to cooperate by describing their pain honestly. Often, he said, men will deny the meaning of pain they experience, and only seek treatment when it is disabling. In public, he said, they display stoic behavior. “Then they go home and curl up on the couch.” Changing that behavior, too, will require considerable education.

© 2002 Lippincott Williams & Wilkins, Inc.