Addressing Psychosocial Factors in Pain Management in the Emergency Department
Pain is widely recognized as a public health problem1 and is one of the most common reasons for emergency department (ED) visits.2 These include visits for both acute pain as well as exacerbations of chronic pain. Pain management in the ED has long been an area of concern, with oligoanalgesia (the under treatment of pain) being of particular concern.2
A number of factors compound the problem of oligoanalgesia. These include physician attitudes, lack of specialized training in managing pain in urgent care settings, and biases related to patient race/ethnicity, gender, and/or age.3,4 This is particularly true with opioids because of concerns about patient misuse.4,5 These factors can lead to low patient satisfaction and insufficient pain relief.
Triage of Pain
When patients present to the ED, pain levels are commonly assessed first at triage. In a comprehensive review article, Motov and Khan identified key challenges associated with providing quality pain management in the ED.5 The authors highlighted deficiencies in pain assessment—including lapses in the assessment of pain levels when patients present with a primary complaint of pain as well as a lack of follow-up at regular intervals to assess pain relief.
Because there is a lack of biomedical diagnostic tests or objective ways to estimate an individual’s pain intensity, patient-reported pain remains the gold standard of pain assessment.6 There are a variety of self-report pain scales. One of the scales most commonly used in the ED is the numeric pain rating scale.7 The individual is asked to rate his or her pain on a scale of zero (no pain) to 10 (worst pain possible). Less frequently used scales include visual analog scales, for which the patient is asked to rate his or her pain intensity on a 100-mm straight line, and non-numeric scales, such as the Faces Pain Scale (often used with younger patients or patients with limited cognitive abilities).8,9
Novel methods of improved pain assessment in the ED, such as the automated pain tracker (APT), are being designed and tested.10 APT, a software application, can be uploaded onto a tablet, which can then be linked with a computer at a nursing station. Patients are able to use APT to report pain levels and the need for more analgesia. A pilot study using the APT showed that the tracker was associated with reduced pain and decreased oligoanalgesia.10
Clinical staff members also rely heavily on their clinical judgment of disease severity/level of tissue damage, as well as behavioral cues displayed by the patient, such as grimacing, to assess pain. Using these clues, clinicians commonly make treatment judgments based on their impression of the concordance between a patient’s pain rating and level of tissue damage, or even their vital signs.11-13 However, empirical studies have shown discrepancies between a patients’ and clinical staff member’s rating of pain assessment, with physicians giving considerably lower ratings than the patient.11 This discrepancy argues for the need for a better understanding of factors that may influence clinical staff member’s subjective judgments about individuals presenting to the ED, as well as about the important predictors of a patient’s experience of pain.
This article briefly reviews the literature on pain treatment disparities. We then share perspectives and preliminary results of studies conducted by researchers at the University of Alabama that examine the influence of psychological variables, including pain catastrophizing and state anxiety (anxiety as a result of a specific or ongoing stressor), on pain levels of patients presenting to an urban ED in the Southeastern United States.
Disparities in Pain Management in ED
Pain relief is one of the most basic health care needs, presenting a moral imperative for adequate pain management in the ED. However, pain treatment disparities are far-reaching and cut across race, sex, and age, with respect to both patient and physician characteristics.4,14 Urgent care settings are not the exception when it comes to disparities in pain management but rather reflect the overall state of the healthcare system.15 Apart from race and ethnicity, empirical evidence suggests that age-related disparities also exist in pain treatment in the ED.16 Published studies indicate that, compared to adults aged approximately 30-60 years, older adults are less likely to receive analgesics during an ED visit for acute pain. Similarly, older adults are less likely to receive opioids for severe pain and may not receive analgesic prescriptions at discharge.16
It is noteworthy that age-related disparities may not be limited to older adults. According to the Institute of Medicine report on pain in America, children have been identified as a vulnerable group in relation to pain management disparities.17 Indeed, previous research has indicated that children and adolescents are more likely to experience under treatment of pain in the ED due to a variety of factors.18
Emerging adults (defined as 18-29 years of age) constitute one of the most understudied populations in relation to pain conditions and disparities in pain treatment. The results of one of the University of Alabama study indicate that emerging adults were half as likely (odds ratio, 0.5) to be administered analgesics during their ED visit, although they reported equivalent levels of pain intensity, duration of current pain, and state anxiety than adults 30 years or older.19 Approximately 40% of emerging adults reported experiencing chronic pain and 23% presented to ED with exacerbation of their chronic pain (lower back pain, migraine, knee pain). Thus, it is imperative that the pain experience of this unrecognized and, consequently, understudied patient population be empirically studied. This would aid in tailoring interventions to address the specific health care needs of this young adult population, ensuring their healthy development and alleviation of pain.
Additionally, those in minority races/ethnic groups, primarily blacks and Hispanics, have long faced disparities in the emergency health care system,20 and this extends to pain treatment in the ED.21 A number of researchers have found that blacks and Hispanics are less likely to receive analgesia although they report comparable pain levels to non-Hispanic whites. However, administrative and clinical efforts focusing on reducing disparities appear to be resulting in improvements. A recent prospective study examining racial disparities over a 10-year period in an urban ED suggests that there were no discrepancies between whites and Hispanics in relation to analgesic administration, wait time, or satisfaction with pain treatment.22 This is consistent with the results of our study at the University of Alabama, such that there were no differences between the likelihood of receiving analgesia based on race or ethnicity.