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Scheck, Anne

doi: 10.1097/01.EEM.0000324842.19922.91

Year after year, the news on pain management for emergency medicine is, well, painful. Although the specialty is making strides in treating pain, new studies continue to reveal fact after distressing fact about how pain is handled in the emergency department.

Last year, in widely reported findings, investigators from the University of California, San Francisco, found that women were less likely to receive analgesia in the ED than men, even though their injuries were the same. (Am J Emerg Med 2007;25[8]:901.) Other studies have shown that serious delays due to ED crowding prevent some patients from receiving appropriate pain relief. (Ann Emerg Med 2008;51[1]:1.)

The data underscore an advocacy campaign being conducted by the International Association for the Study of Pain (IASP), which declared 2008 the year against pain in women. From the IASP headquarters in Seattle, executive director Kathy Kreiter expressed support for those who have turned an investigative glare on differences like the UCSF study revealed. “There's a general lack of awareness” about the issue, she said. Differences in the way pain is perceived, the kind of emergencies that cause it, and the individual variables among those affected by it make it difficult to study.

Pain is perplexing, even bedeviling, for emergency physicians. From a legal standpoint, it is considered “an entirely subjective experience,” or even more ambiguously “whatever the patient says it is,” because the most reliable indicator is considered self-reporting. (J Legal Med 2006;27[4]:427.) Cultural influences can affect pain perception, as can stress and age. “Race, for example, may explain pharmacokinetic and pharmacodynamic differences,” commented Kenneth Sakauye, MD, a professor and the vice chairman of psychiatry at the College of Medicine at the University of Tennessee Health Science Center in Memphis, in a publication on pain management in the elderly. “Culture would predict dietary differences that might influence medication absorption or metabolism, communication styles, or acceptance of treatment,” he wrote. (Compr Ther 2005;31[1]:78.)

In fact, though more than half of ED patients complain of pain, many studies have shown the most likely person to get adequate relief in the ED is a Caucasian man, despite the fact that a majority of patients treated in a typical ED are women, children, and nonwhite patients of various backgrounds. This past January, researchers from the University of Alabama at Birmingham and the University of California, San Francisco, found that physician prescribing practices varied between white and nonwhite patients. These differences were large and statistically significant, and they generally increased with pain severity. (JAMA 2008;299[1]:70.)

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Physician Ratings

These data have implications that go beyond equity; they can affect physician ratings directly. Pain is one complaint that can make the difference between a doctor being seen as a health care saint or an uncaring incompetent. Pain relief makes for high patient satisfaction; lack of it, or delays in receiving it, has the opposite effect. And as physician report cards become commonplace, patient satisfaction ratings in the ED are becoming more closely associated with pain relief. At some centers, pain scores by diagnosis-related group already are an important part of quality measurement. (Phys Exec 2007;33[6]:10.)

Moreover, the situation in EDs is likely to become a lot worse, at least in terms of patient demand, as the longer-living baby boomers suffer more age-related injuries, including bone and joint stress and fractures from overusage and falls, both of which dramatically increase in seniors and are a frequent cause of hospitalization. (This year, insurers have started expanding their longevity tables to reflect the possibility that human lifetimes will pass the 100-year mark, necessitating coverage for the very aged elderly.)

As emergency medicine has taken a hard, empiric look at pain management, some key solutions have emerged. Among them are triage methods to improve delays, electronic medical records that might detect drug-seeking behavior, and higher dosing to attain an adequate analgesia level. At the University of Utah ED, for example, triage pain protocols have cut time-to-intervention duration almost in half, and all it took to accomplish that was heightened awareness and a 15-minute nursing in-service at the start of the study. (Am J Emerg Med 2007;25[7]:791.)

Similar programs are being carried out elsewhere, too. Pain now is considered a vital sign at his emergency department, and is assessed by triage nurses as an initial step in the treatment process, said Jesse M. Pines, MD, MBA, an assistant professor of emergency medicine at the University of Pennsylvania School of Medicine in Philadelphia. He and colleague Judd Hollander, MD, used a 1-to-10 scale in a recent study, with 10 being the highest pain level. “A lot of time, we don't know how much pain a patient is having unless we ask,” Dr. Pines observed. “Using pain as a regular part of the emergency assessment is working well.”

This triage assessment helps identify pain symptoms that might otherwise go unrecognized. Some patients in real pain may not demonstrate signs of discomfort, he noted. These disparities are exacerbated during times of ED crowding. “When we recently looked at 17 months of data from our ED, the level of crowding was directly related to both the use and timely administration of pain medications for patients with severe pain,” he said, adding that how busy a department is and the practice of ED boarding makes it difficult for ED providers to offer the best possible pain control.



One factor that may influence data from this study is a human one: Do patients exaggerate symptoms so they can be seen faster? Or is it that patient symptoms in crowded conditions tend to worsen or are perceived as worse due to the wait they have to endure before receiving medical attention? The answers to those questions aren't yet clear, he said.

About 10 years ago, though, psychologists began commenting on, for lack of a better term, what is called the “ow factor.” Anecdotally, patients who seemed the most uncomfortable seemed the likeliest to receive pain relief. Because visual scales are widely used, it has been proposed that long-term records of them might provide a glimpse of how patients' perceptions of pain might change over time. Do patients writhing in pain over a migraine grow more accustomed to the discomfort, for example, even if they tend to react the same way?

But visual analog scales simply aren't dependable over multiple visits, according to most emergency physicians. “VAS scales are really only accurate for measuring changes in pain within a single visit for a single patient,” said James Miner, MD, an associate professor of emergency medicine at the University of Minnesota and Hennepin County Medical Center in Minneapolis.

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Long-Term Effects

Pain affects an ED in an important, recurrence-predicting way in that its chronicity is linked to depression, even in children. It is known to cause post-traumatic stress disorder in kids, particularly if it occurs in an ED, wait times are involved, and inadequate relief occurs. This can have long-term effects on future pain responses. (Ann Emerg Med 2005;45[2]:160.) In households in which there is an adult chronic-pain sufferer, financial losses can be substantial and profoundly affect the other members in the home. (J Pain Symptom Manage 2002;23[5]:433.)

Because there is a scientifically valid link between depression and pain, some investigations are looking at what happens when pain medication is not available for patients who need it. The answer so far looks fairly grim. People in pain tend to seek relief in ways available to them, with over-the-counter agents or alcohol, for example. One study of opiod use, for example, tallied calls for opioid exposure to a poison control center, which were significantly higher in “dry” counties where the sale of alcohol was severely restricted or banned. (Clin Toxicol 2006;44[5]:20.)

The electronic medical record may help medical staff make an earlier determination about whether a patient is drug-seeking or legitimately needs pain relief. “It would be very helpful if we had some central way to access information on local ED use. If we could know that they had just been discharged from the ED across town, this would help us make treatment decisions. In the current system, we often don't have this information,” Dr. Pines said.

In the article, “Grounding Frequent Flyers, Not Abandoning Them,” two state programs are highlighted in Kentucky and California to show how drug dispensations can be tracked and monitored. Two years ago, Kentucky launched the nation's first web-based self-service system enabling pharmacists, physicians, and law enforcement officials to follow schedule II-V drug dispensations in real time. California's Bureau of Narcotic Enforcement now operates a controlled-substance tracking system that sends physicians a patient-activity report if a patient under their care has received prescriptions for schedule II, III, or IV drugs from multiple providers. (Ann Emerg Med 2007;49[4]:481.)

Will these modifications to current systems help expand the record to make “frequent flyer” detection more effective? Interestingly, though drug crime often is seen as a source of abused pain medications in the United States, it focuses heavily on physician prescribing and patient abuse, though theft and diversion from pharmacies and other sites account for most of the loss. (J Pain Symptom Manage 2005;30[4]:299.) Nonetheless, headline-making cases about physicians overprescribing pain medication, particularly opioids, have made the medical profession leery of appearing too lax in providing access to the drugs.

That's prompted strong counterarguments recently, some of which are now appearing in the medical literature. David Joranson, MSSW, and Aaron Gilson, PhD, of the University of Wisconsin's Pain and Policy Studies Group, for example, issued just such a warning in a letter accompanying the drug-diversion study. “If we accept uncritically that drug diversion stems only from prescriptions, we risk distorting our view of the medical profession and patients through a lens of substance abuse, which further weakens physicians' desire to treat pain and worsens patient access to pain care,” they wrote.

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© 2008 Lippincott Williams & Wilkins, Inc.