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11 Articles in Volume 14, Issue #10
Combating Opioid-Induced Constipation: New and Emerging Therapies
Updates on Smoking and Low Back Pain
Unraveling the Psychological Mechanisms Behind Smoking in Chronic Pain
Addressing Psychosocial Factors in Pain Management in the Emergency Department
Long-Term Outcomes and New Developments in Juvenile Fibromyalgia
Pain Management in the Elderly: Etiology and Special Considerations
Using Pharmacogenetic Testing in a Pain Practice
Editor's Memo: Care With Caution
Ask the Expert: HIPAA Rules
Ask the Expert: DMARDs and Opioids
Letters to the Editor: November/December 2014

Addressing Psychosocial Factors in Pain Management in the Emergency Department

In addition to assessing pain levels through a self-report scale, it is also important to assess psychological factors, such as catastrophizing and anxiety, to adequately manage acute and chronic pain 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.

Chronic Pain in the ED

Although urgent care settings traditionally were set up to manage acute conditions, almost half of the patients presenting for urgent care are those with exacerbations of chronic pain or recurrent pain.23 Patients with chronic or recurrent pain report visiting the ED several times because this setting provides 24-hour access to healthcare.24 However, given that emergency care providers are expected to provide acute care, often with patients presenting with life-threatening situations, repeated visits by patients with chronic pain, commonly with multiple physical comorbidities, may generate frustration in both the patient and the provider. A body of evidence corroborates the relationship between psychological distress/depression/anxiety and the experience of persistent pain.25. Moreover, extant research on pain in the ED has excluded such individuals whose source of pain cannot be verified, leaving little scientifically valid information regarding the possible differences between patients with acute pain and those with chronic pain.

The study conducted at the University of Alabama evaluating patients presenting with exacerbations of chronic pain, those presenting with acute pain, and those with acute pain who also experienced chronic pain.26 The results indicated that there were significant differences between those pain groups, with patients with exacerbations of chronic pain reporting the greatest levels of pain catastrophizing and those with acute pain reporting the lowest levels of catastrophizing. Surprisingly, there were no differences between the levels of anxiety between the groups. Given that patients with chronic pain consistently have been shown to be high users of health care, including urgent care, it is prudent to refer patients presenting to the ED with exacerbations of chronic pain for psychological interventions and pain management to reduce suffering and facilitate more efficient use of health care resources.

Psychological Distress

Patients presenting for urgent care with a primary complaint of pain commonly experience concurrent psychological distress.27,28 In addition, long wait times, delays in receiving analgesics, and insufficient pain relief, even after analgesic administration, may lead to heightened emotional distress.2 Since pain is not a unidimensional sensory experience but rather a perceptual phenomenon, psychological processes, both affective and cognitive, greatly influence an individual’s pain.29

There is robust evidence highlighting the role of increased anxiety, depression, and pain catastrophizing in intensifying perceived pain and suffering. Despite there being extensive literature and anecdotal clinical evidence corroborating such an association, there is a paucity of research pertaining to overseeing pain management in conjunction with psychological distress in urgent care settings.

In the University of Alabama study, patients presenting with a primary complaint of pain completed measures pertaining to pain intensity and psychological variables, including state anxiety and pain catastrophizing. The results of the study suggest that levels of pain catastrophizing and state anxiety significantly predicted self-reported pain levels of patients presenting with acute pain.30 Moreover, mediation analyses indicated that the patient’s level of catastrophizing mediated the relationship between state anxiety and self-reported pain rating at triage. However, it is important to be mindful that these results indicated that pain catastrophizing is a mediator, but they cannot prove causality because of the cross-sectional nature of the data.

The results of the second University of Alabama study mirror those of the first, indicating that there were significant differences between pain groups, with those with exacerbations of chronic pain reporting the greatest levels of pain catastrophizing and those with acute pain reporting the lowest catastrophizing. Again, there were no differences between the levels of anxiety between the groups.26,30

It is important to note that these findings do not indicate that distressed patients are experiencing psychogenic pain; instead, the findings underscore the importance of affect and cognition in the multidimensional experience of pain. Thus, it is likely that without addressing the associated cognitive distress of the patient with pain, it will be difficult to provide either adequate analgesia or a level of patient satisfaction that is expected of the ED staff. This, in turn, highlights the importance of assessing and treating the psychological distress in conjunction with pain intensity.

Practical Suggestions

Based on our experiences and the results of the studies discussed, we offer these brief suggestions for managing the psychological distress of patients presenting to the ED with pain to promote better patient outcomes (Table 1).

Discussion

Managing pain and providing adequate analgesia in the ED is a challenge, especially when patients are elderly or young adults. As discussed, researchers have identified an important potential age-related disparity in pain treatment with emerging adults (patients aged 18-29 years). These young adults are less likely to receive analgesics during an ED visit than adults and older adults. This population is virtually unstudied in relation to pain disparities, underscoring the need for further research.

The results also indicate that psychological variables play a crucial role in the pain intensity ratings given by patients. Additionally, there were important differences in these variables among those presenting with exacerbation of a chronic pain condition, those with only acute pain, and those with acute pain who also experience chronic pain. Application of knowledge regarding some of the common disparities associated with pain management as well as the importance of cognitive distress in patients’ experiences of pain might help reduce oligoanalgesia in EDs.

Last updated on: May 12, 2017
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