Pain is common in the emergency department (ED), representing up to 78% of presenting complaints.[1] Emergency physicians (EP) must therefore be experts in the management of pain. Right? Let’s examine how well we do.
Reality Check
A 2007 study examining pain practices in 17 EDs in the US and Canada analyzed 842 patients with moderate to severe pain (pain greater than 3 out of 10) identified multiple deficiencies in ED pain management. Across the spectrum of pain severity, EP undertreated pain: only 70% of patients with severe pain received analgesia. Only 50% of the included patients had a clinically meaningful reduction in pain (2+ point reduction), and 75% of patients were discharged with moderate to severe pain.[1] These results lack generalizability to the greater ED population, as the study only included a convenience sample of discharged patients, and had multiple exclusion criteria including intoxication and “inadequate contact information.” Furthermore, providers may have altered their practices if they knew they and their patients were being studied, also known as the Hawthorne effect. Despite these constraints, this study offers evidence that ED patients’ pain is often undertreated. Herein we’ll refer to undertreated pain as oligoanalgesia.
Patient desire vs administration of analgesic [1]
Children are not just small adults (but should get analgesia anyways)
Well even if we don’t treat pain perfectly, surely we don’t let vulnerable patients suffer… right?
Brown et al studied 2828 pediatric and adult patients in the US with isolated closed fractures of extremity or clavicle.[2] Pediatric patients were less likely than adults to receive analgesia (53% vs 73%). Among patients, less than 4 years of age with moderate to severe pain, only 62% received analgesia compared to 73% overall. Those on the other extreme of age did not fare much better: 62% of patients age 70 or older with moderate to severe pain received analgesia. This retrospective chart review limits the certainty of the findings, as there are inherent biases associated with chart abstraction. For example, it’s possible that analgesia was given but not documented. However, the large sample size and concordance with similar studies provides unfortunate evidence that both the young and old may receive discordant analgesia compared with the overall population.
Proportion of patients receiving analgesia [2]
Racial biases in pain medication
Prior studies have shown that non-white patients often have worse outcomes. For example, This has been shown with higher mortality rates among black pregnant women.[3] Does racial bias exist in our pain management in the ED?
Simply, yes. Two studies by Goyal et al demonstrated differences in pain prescribing practices based on race in the US. If that’s not bad enough, the studies were in pediatric patients. The first study, a retrospective review of pediatric patients with long-bone fractures found African Americans and Hispanics were less likely to receive opiates or achieve optimal pain relief.[4] The second study, a cross-sectional analysis of pediatric patients diagnosed with appendicitis found black patients were less likely to receive opiates or receive analgesia for moderate pain.[5] Both studies consistently demonstrate that EPs treat pain differently based on race.
Probability of any or opioid analgesia for moderate pain with appendicitis [5]
What are the harms of inadequate oligoanalgesia?
Anyone who has worked in the ED never wants to hear the wailing of a patient in pain. Yet despite the moral obligation to treat pain, what are the short and long-term consequences of oligoanalgesia?
| Acute Complications | Chronic Complications |
| Delirium | Delay in physical recovery |
| Hyperglycemia | Complex regional pain syndrome |
| Immunosuppression | Post-traumatic stress disorder |
| Hypercoagulability | |
| Increased morbidity and mortality |
Where do we go from here?
Dr. Shibata previously discussed oligoanalgesia and offers us some solutions.[7]
From her excellent post:
First: Stop saying that it’s not you. It is you! You suck at managing pain. Perhaps not in everyone, but you’re definitely mistreating someone. Once we accept this fact, we may become cognizant and then able to improve our practices.
Second: Educate thyself. Tintinalli’s actually has a whole chapter on acute pain management. Studies show that short training sessions led providers to give more analgesia with improvement in patient satisfaction (5).
Third: Simply ask. Ask your patients if they have pain and ask them if they want pain medication.
Fourth: Don’t get caught up by stupid myths. Your patient is in pain, treat him/her!
Last: Do not give in to the Great Opiophobia! We are emergency physicians and we aren’t afraid of anything!
Take-Home:
- 1. Emergency physicians may undertreat pain
- 2. Young and old are especially vulnerable to oligoanalgesia
- 3. Racial biases exist in pain management
- 4. Oligoanalgesia does not come without harms
- 5. Treat pain
References:
[1] Todd KH, Ducharme J, Choiniere M, et al. Pain in the emergency department: results of the pain and emergency medicine initiative (PEMI) multicenter study. J Pain. 2007;8(6):460-466. doi:10.1016/j.jpain.2006.12.005
[2] Brown JC, Klein EJ, Lewis CW, Johnston BD, Cummings P. Emergency department analgesia for fracture pain. Ann Emerg Med. 2003;42(2):197-205. doi:10.1067/mem.2003.275
[3] Callaghan WM. Overview of maternal mortality in the United States. Semin Perinatol. 2012;36(1):2-6. doi:10.1053/j.semperi.2011.09.002
[4] Goyal MK, Johnson TJ, Chamberlain JM, et al. Racial and Ethnic Differences in Emergency Department Pain Management of Children With Fractures. Pediatrics. 2020;145(5):e20193370. doi:10.1542/peds.2019-3370
[5] Goyal MK, Kuppermann N, Cleary SD, Teach SJ, Chamberlain JM. Racial Disparities in Pain Management of Children With Appendicitis in Emergency Departments. JAMA Pediatr. 2015;169(11):996-1002. doi:10.1001/jamapediatrics.2015.1915
[6] Highland EM Ultrasound. Block anatomy. Highland EM Ultrasound website. Accessed July 29, 2021. http://highlandultrasound.com/multimodal-analgesia
[7] Shibata J. Oligoanalgesia. County EM website. Accessed July 29, 2021. http://blog.clinicalmonster.com/2015/02/09/oligoanalgesia.
Robby
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