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7 Articles in Volume 1, Issue #5
Accidentally Speaking
Breaking Down the Barriers of Pain: Part 5
Cancer Pain: Successful Management of Patients’ Fears
Emergency Medicine: Emergency Department Protocols
Magnets & Medicine
The Neural Plasticity Model of Fibromyalgia Theory, Assessment, and Treatment: Part 3
Thinking About Pain

Emergency Medicine: Emergency Department Protocols

Improving pain management in the ED provides better treatment options for patients.

It is easy for health care practitioners to identify with the patient who has severe pain resulting from a kidney stone or an acute femur fracture. However, it may be difficult to identify with a patient who has chronic back pain, yet has no obvious findings on exam. Clinicians need to believe the patient’s assessment of pain. This is not always easy but is extremely important.

Pain is always subjective1 and for many health care providers this is a difficult concept. Clinicians are more comfortable with problems that can be diagnosed on exam or by ordering a test. However, there is no test that can prove or disprove a patient’s complaint of pain. Not vital signs, a patient’s facial expressions, or “gut instincts” can be used to invalidate a patient’s rating of his or her pain.

Pain is the most common presenting symptom in the Emergency Department (ED). More than 60 percent of ED patients have pain as their main symptom or a major part of their symptoms. When a patient in pain enters the ED he or she has two main concerns (not necessarily in this order):

  1. How quickly can I get relief from my pain?
  2. What is causing this pain?

The major focus of health care professionals is:

  1. What is the diagnosis?
  2. What is the treatment for the underlying disease process?

Often a lower importance is placed on relieving the pain. This leads to discordance between the expectations of the patient and the focus of the health care provider.

So how good a job are most practitioners doing at treating and assessing pain in the ED?

In a recent study of patients presenting to an ED with a complaint of pain, two-thirds never had an assessment of their pain documented. Of these patients, only one-third ever had a re-assessment of their pain (i.e. “Did the analgesic we gave you help?”). Upon discharge from the ED, 43 percent of patients were still in moderate or severe pain.2

Many studies have shown that there are inadequacies in how pain is treated. In a post-operative study, approximately 50 percent of patients felt that their post-operative pain management was inadequate. A study of a busy urban emergency department shows that in patients with a long bone fracture, the risk of receiving no analgesic while in the ED was 66 percent higher for African-Americans than for white patients.3

 

Barrier to Effective Pain Management

One of the large barriers to effective pain management is lack of formal education on this subject in training. Unfortunately many medical schools designate only one to four hours (over the four years of medical school) to the subject of analgesia. Many physicians are left to “pick-up” knowledge on this subject while on clinical rotations. Residents tend to follow the example set by the resident who is one year ahead. They in turn gain their knowledge of analgesia from the residents one year ahead of them, and so on. Most of training on treating pain is anecdotal and passed down from generation to generation. It is because of this system that many doctors still prescribe propoxyphene, codeine, meperidine, and stadol instead of medicines with a much better benefit to risk ratio.

 

New Pain Management Standards

Recognizing difficulties, several organizations have set guidelines for pain management. These guidelines include those from the American Pain Society, the World Health Organization (WHO), and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). These standards apply to emergency medicine as much as they do to surgery and other specialties. Recently enacted JCAHO standards set forth several basic principles that are consistent with effective pain management. Essentially these guidelines guarantee patients the right to effective pain management. In addition, health care practitioners should ask patients a screening question to identify those patients in pain. For those presenting pain, an assessment of this pain should be performed and documented. Relevant staff should be educated in pain assessment and management and patients should be involved in making decisions about the treatment of their pain.

Finally, the health care facility should establish policies and procedures that support appropriate prescription or ordering of effective pain medication.4

Now that JCAHO will evaluate health care facilities for compliance with these standards, it is important that these guidelines be followed. Many hospitals are setting their main focus on “being in compliance” with the standards. Clinicians should change their focus to setting goals on practicing excellent pain management including choice of medications/therapies, assessment, documentation, and education of staff and patients.

 

Pain Management Improvements

There are many ways in which pain management can be improved upon in the ED.

Simplistically, this can be divided into two main areas. The first area deals with the clinician’s approach toward pain management. This includes concepts, preconceived notions, biases, and habits as well as the approach toward and feelings about patients in pain. The second area deals with specific technical details about pain management (medicines, route of administration, etc).

There are many options available to practitioners, many which are simple and effective to implement.

  1. Inform patients of available PRN analgesics. Explain to the patient the meaning of PRN and how this can assist him or her.
  2. Be careful of potentially toxic doses of acetaminophen. Careful dosing is of particular importance. For example, >4 grams/day or >3.2 grams/day in elderly patients. It’s also important to monitor those receiving multiple doses of opioid/acetaminophen combination, i.e. Darvocete-n 100,6 tablets/day = 3.9 grams of acetaminophen or Vicodin, 8 tabs/day = 4 grams of acetaminophen.
  3. Effective method for vertebral fracture pain. For vertebral fractures, calcitonin does a wonderful job in decreasing the severity and duration of pain.
  4. Use a block for rib fractures. An intercostal block can often be effective in treating rib fractures.
  5. Prescribe an incentive spirometer. This can be useful for patients with painful chest or abdominal trauma to decrease the risk for atelectasis.
  6. Do not encourage prolonged bed rest for patients with back pain. After one to two days patients should be encouraged to resume activities.
  7. Use a block for toothaches. An alveolar ridge block can be effective for toothaches.
  8. Use a combination of local anesthesias. A combination of xylocaine (rapid onset) along with a long acting agent such as bupivicaine or marcaine may be effective.
  9. Prescribe NSAIDs for certain conditions. NSAIDs are especially effective in treating musculoskeletal pains (arthritis, sprains, fractures) as well as renal colic, gout, and dysmenorrhea. However NSAIDs have a ceiling effect. For each NSAID there is a dose above, which there is no further analgesic effect but side effects are more likely. One of the major potential side effects of NSAIDs is GI toxicity including bleeding. This is a systemic effect as opposed to a local effect and ketorolac (Torodol) even if given IV carries this potential side effect.
  10. Use Cox-2 selective inhibitors (coxibs) appropriately. Compared to non-selective NSAIDs, these agents have the advantage of lower risk of GI toxicity (perforations, ulcers, and GI bleeding) and not interfering with platelet function. Of these two agents, only rofecoxib (Vioxx) has an indication for treating acute pain.5 However, as with the non-selective NSAIDs, the coxibs pose a similar risk for renal and blood pressure related side effects. There are three situations where the author feels it would be preferable to prescribe a coxib as opposed to a non-selective NSAID:
    * In those patients where a NSAID would be used, but the patient is at risk for developing a NSAID related GI bleed. These risk factors include older age, prior GI bleed or prior ulcer disease, alcohol abuse, warfarin use, steroid use, CHF, aspirin use (even low dose aspirin), and severe pre-existing medical problems;
    * The patient is at risk for bleeding (at a site other than the GI tract) secondary to surgery or traumatic injury;
    * A patient requests a medicine that can be taken once/day.
  11. Believe the patient’s assessment of pain. This is not always easy but is extremely important.
  12. Give adequate doses of analgesics while the patient is in the ED. Often physicians use their preconceived notion of how much analgesic a patient should require and are reluctant to adjust this to meet individual needs (i.e. this patient has a kidney stone and will require a maximum of 10 mg of morphine). Instead tailor the amount of analgesic given to the patients needs. Be willing to continue giving analgesics until the patient feels that they have received enough.
  13. Document the patient’s response to treatment.
  14. Prescribe an adequate amount and strength of analgesics upon discharge.
  15. Avoid IM Injections6: IM injections are painful. They can cause fibrosis, sterile abscesses, and in rare cases, nerve injury. (Often the pain from an IM injection will last much longer than the initial painful condition). Absorption from an IM injection is erratic. If an IV cannot be established and a parenteral injection is required consider giving a sub-q injection or PCA via a sub-q infusion.
  16. Avoid Demerol (meperidine). Many physicians become defensive when this is mentioned, but here are some facts. The metabolite of meperidine is normeperidine (NM) that has a duration of action/half life far longer than the parent compound. NM has several adverse effects. It can cause agitation, restlessness, disturbed sleep, and in certain patients may precipitate seizures. Because of its long half-life, NM accumulates with time if multiple doses of Demerol are administered. Oral Demerol produces even higher levels of NM (and more side effects) for a given level of analgesia. There is no preferential advantage to Demerol in treating pancreatitis or biliary colic.7 It is medical folklore that morphine is more likely to cause spasm of the sphincter of Odie. This belief was based on animal studies done approximately 50 years ago. In patients there is no benefit of using Demerol vs. morphine.
  17. Do not routinely administer a sedative or anti-emetic along with analgesics. An example is Demerol and Vistaril (Hydroxyzine) or a benzodiazapine. This combination increases sedation and may increase respiratory depression, but does not improve analgesic efficacy. In addition, IM Vistaril injections are very painful.
  18. Prevent pain before it begins. Administer analgesics before performing painful procedures. Examples include: NG tube insertion (use Neosynephrine spray and topical Lidocaine gel prior to insertion); Foley catheter insertion (Lidocaine gel); and abscess drainage (IV or PO analgesics along with local anesthetics prior to incision).
  19. Treat pain aggressively. The term “wind-up phenomenon” is used to describe the development of increasing pain from a given stimulus (secondary hyperalgesia). “Wind-up” occurs when a pain impulse travels to the Dorsal Horn Neuron (DHN) in the spinal cord. Here a memory is established. When a future pain stimuli travels to this DHN, the pain signal forwarded to the brain will be greatly magnified. If pain is treated aggressively early on, or in the case of surgical patients if pain is treated “preemptively” prior to surgery, doctors may be able to minimize this. Treating pain aggressively, early in the course of an illness or injury may prevent long-term consequences (disability, atelectasis, DVT, etc.) and minimize the risk for developing chronic pain.
  20. Opioids are very useful in managing both acute and chronic pain. In their consensus statements, the American Pain Society and the American Academy of Pain Management state, “Opioids are an essential part of a pain management plan.”8 Opioids have no ceiling effect. The dose of opioid can be gradually increased until adequate analgesia is obtained or until side effects limit further dosage increase.
  21. Do not use the term narcotic. This term has negative and counter-productive connotations to patients and to health care providers.
  22. Anticipate side effects. Provide for treatment of these if they should develop. For example, opioids routinely cause constipation and may cause nausea. Constipation is best treated with a bowel stimulant/stool softener combination (such as senneca/ducosate: Sennekot-s and others two to six tablets/day). Provide the patient with a prescription for an anti-emetic in the event that nausea occurs.
  23. “Treat by the clock.” Patients who will have pain for more than 12 hours/day will have better analgesia and possibly fewer side effects if they are given analgesics on a set schedule (based upon the half-life of the analgesic) rather than waiting for the pain to increase and then taking the medicine on a PRN basis (example: hydrocodone q 4 hours, Oxycontin q 12 hours). This will give a more even analgesic effect and prevent the cycle of pain/pain relief associated with side effects/recurrent pain that often occurs with PRN dosing.
  24. Practice “Balanced Analgesia.” Combinations of analgesics often work better than relying upon high doses of a single agent. An example of this is the combination of an opioid along with a NSAID, such as Oxycodone and Ibuprofen. However, it is best to use only one drug from a given class at one time For example, use only one opioid and one NSAID.
  25. Patients on long-term opioid therapy have developed tolerance to some degree. If the patient presents with an acutely painful condition, he or she will require higher opioid doses than the opioid-nanve patient. It is reasonable to increase the opioid dose to 125-150 percent of the current opioid dose for these patients.
  26. Avoid Codeine. Codeine is a very weak opioid (60 mg is comparable to 650 mg of acetaminophen). It also tends to cause much more nausea and constipation than other opioids. The maximum dose of codeine is limited by these side effects. In addition, approximately 10-15 percent of the population lacks the enzyme required to convert codeine to its active metabolite - morphine.
  27. Avoid Propxyphene. Darvocete, etc. is also a very weak analgesic (100 mg is comparable to 650 mg of acetaminophen9) . Often elderly patients are given this medicine because doctors are concerned about giving them something that is too strong. However, propoxyphene has poor analgesic efficacy. It can cause sedation and increase the risk of falling. Patients may like propoxyphene because of the “buzz” they receive but do not receive as much analgesia as with other opioids.
  28. Consider using long-acting opioids. This is effective when a patient is anticipated to have pain for >24 hours. For example Oxycontin q 12 hours on a standing schedule as opposed to using rapid release preparations of oxycodone has been shown to decrease sedation and nausea, improve pain relief, and lead to a decrease in total dose of opioids used.
  29. Goals for treating acute pain and chronic pain are different. With acute pain the goal is to relieve pain while treating the underlying cause of the pain. In chronic pain it is often not possible to treat/eliminate the cause of the pain and the goals change to helping the patient to regain control of his or her life. This includes enabling them to participate in their ADL’s, enjoy their recreational activities, and to be able to return to work.
  30. Be willing to prescribe Patient-Controlled Analgesia (PCA). As the name implies this approach places the patient in a position of control over the treatment of their pain. PCA can either be IV, PO, or sub-Q. Oral PCA can be done with a long acting opioid preparation on a set schedule along with a lower dose of a rapid release preparation of the same opioid to be used as needed between these doses. An example of this would be Oxycontin q 12 hours along with Oxy-IR q one to two hours as needed.
  31. Write Prescriptions wisely. Write the quantity and strength in both letters and numbers, and then draw a tight circle or box around these. Write the patient’s address on the prescription. If possible use tamper resistant prescription pads.
  32. Refer patients. In the ED, doctors are able to take care of acute exacerbations of chronic pain but on-going long-term care is best done by the patient who has established a relationship with a primary care provider or pain clinician.
  33. Do not wait until the diagnosis is made to treat pain. For patients with acute abdominal pain it is indicated to provide analgesic while the evaluation is in process. Many physicians believe that opioids should be withheld until the final diagnosis is made (out of fear of masking symptoms of pain). According to Silan, “This cruel practice is to be condemned, but I suspect that it will take many generations because this rule has become so firmly ingrained in the minds of physicians.”10

 

Summary

There are many steps that can be taken to improve the overall performance of managing pain in the ED. These include treating pain aggressively, prescribing appropriate medications, treating chronic pain differently than acute pain, preventing pain before it begins, etc. Changing the way pain is treated will help pave the way for complying with new JCAHO pain guidelines and standards. Goals should be set on practicing excellent pain management including choice of medications/therapies, assessment, documentation, education of staff and patients, etc. By practicing excellent pain management, this will bring heath care practitioners toward the other goal of complying with JCAHO standards.

Last updated on: January 28, 2012
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