Pain Management in the Emergency Department

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The management and treatment of the pain in the emergency department (ED) is unique from that experienced in other medical settings. Not only is pain often acute as opposed to chronic, but it is often unexpected and sudden. In addition, the type of painful conditions seen in the ED may respond differently to different types of treatments, such as the pain from a migraine versus the pain from a kidney stone. In these and other ways, the acute pain that is seen in the ED is different from the acute pain seen postoperatively, the latter of which is both expected and planned for.

Acute pain generally lasts less than seven days but can extend up to 30 days, and in some cases can become chronic. Therefore emergency physicians are challenged to provide adequate pain relief, improve quality of life, and improve function while simultaneously trying to minimize adverse effects, including mitigation of the risk of addiction from the use of opioids, both in the ED and upon ED discharge.

Prevalence and Assessment of Pain in the ED

Pain is one of the most common reasons for patients to come to the ED. The prevalence of pain among ED patients is approximately 45% based on cross-sectional data from the National Hospital Ambulatory Medical Care Survey, though the percentage of patients reporting severe pain increased from 25% in 2003 to 40% in 2008.

Since the ED serves as a fail-safe mechanism for our fragmented healthcare system, chronic pain patients also present to the ED with acute exacerbations of their chronic pain. Extrapolating the results of a national telephone survey of 500 patients suggests that 34 million adults with chronic or recurrent pain visit the ED at least once every two years. Of this group, 43%, or 15 million, experience recurrent pain, while 57%, or 19 million, have underlying chronic pain syndromes. The number of chronic pain patients visiting the ED has likely increased because some patients have had their opioid prescriptions suddenly reduced because of physicians’ responses to the opioid epidemic.

Notwithstanding the issue of providing compassionate care, pain that is not acknowledged and managed appropriately can cause anxiety, depression, sleep disturbances, increased oxygen demands with the potential for end-organ ischemia, and even decreased movement, which can lead to an increased risk of venous thrombosis. Failure to recognize and treat pain may also result in dissatisfaction with medical care, hostility toward medical staff, unscheduled return visits to the ED, delayed return to full function, and an increased risk of litigation.

Pain is inherently subjective and inevitably complex, with each patient experiencing pain and suffering as an individual. As physicians, we assess our patients’ pain indirectly and sometimes with skepticism. The validity of patient self-reports is often questioned and attempts to “objectify” the pain experience are sought, but no such biomarkers exist. In contrast, patients themselves, especially older adults, may be reluctant to report pain presence and intensity. This may result from low expectations of obtaining pain relief, fear of analgesic side effects, and a notion that pain is to be expected as part of the underlying disease or from medical treatments. In addition, some patients have a fear of addiction when prescribed opioids or fear the stigma associated with opioid use, including from a single dose of intravenous opioids for acute severe pain in the ED.

Pain assessment can be difficult in the ED, where time frames are often compressed, and therefore simpler assessment tools are generally preferred. Although far from perfect, the two most commonly used are the 11 point verbal numeric rating scale, in which pain is rated on a scale of 0 (no pain) to 10 (worst possible pain), and the verbal descriptor scale, in which pain is categorized as none, mild, moderate, and severe. These scales are also preferred by cognitively intact elderly ED patients. No matter the specific pain scale used, assessments should be repeated after therapeutic interventions. Simply asking the patient the question, “Do you want more pain medication?” may be an alternative way of judging whether adequate pain relief has been obtained since individual patients have different thresholds of acceptable pain and may balance pain severity against side effects, such as nausea and sleepiness. A non-numeric yes or no question may also be easier to comprehend among mildly confused patients, older adults, and those distracted by the severity of their pain.

The Problem of Balancing Undertreatment of Pain and the Risk of Addiction

In 1989, Wilson and Pendleton coined the term “oligoanalgesia” in ED patients after performing a chart review of 200 ED patients. This and subsequent studies found that analgesics were underused in the treatment of pain in ED patients in a significant proportion of patients. A few years later, pain became known as the “fifth vital sign,” and relieving pain became a national priority adopted by various societies, including The Joint Commission, the Institute of Medicine, and the now defunct American Pain Society. As a result of these and other efforts, the amount of prescription opioids prescribed and sold in the United States quadrupled from 1999–2010. Not surprisingly, the number of opioid overdose deaths also quadrupled. Something had to be done though in some ways the pendulum may be swinging back too far to the other side, an example of which is the abandonment of some chronic pain patients.

Although some patients may decline opioid analgesics because of concerns about addiction, the ED is also frequently targeted by patients addicted to opioids. Professional discussions of pain in the ED often center on concerns of being duped by patients who fabricate symptoms to obtain opioids, so-called drug-seeking behavior. Strategies to help with chronic pain patients demanding opioids in the ED are listed in Box 76.1 .

Emergency physicians frequently struggle to balance appropriate relief of acute severe pain and prevent addiction to opioids. In managing pain complaints, emergency physicians are responsible for beneficence and nonmaleficence. They must treat pain and ameliorate suffering while minimizing the extent to which their decisions enable substance abuse and increase the supply of prescription opioids available for abuse by the general public. Fortunately, certain tools, such as online state prescription monitoring programs, can aid emergency physicians in differentiating appropriate and problematic requests for opioid analgesics.

Pain Treatment

Effective pain management involves both pharmacologic and nonpharmacologic modalities. A recent systematic review on acute pain was published by the Agency for Healthcare Research and Quality. Simply asking about pain and validating patients’ reports of pain has a potent effect on patients’ satisfaction with ED pain management. In one study, patient satisfaction with pain management was predicted more strongly by the perception that ED staff asked about pain than the actual administration of an analgesic. Other modalities such as reassuring the patient that pain will be addressed, immobilizing and elevating injured extremities, and providing quiet, darkened rooms for patients with migraine headaches are essential aspects of quality pain management that can result in decreased amounts and use of opioids.

Analgesics may be administered by various routes. However, most analgesics are administered in the ED either orally or parenterally. Oral therapies are most commonly used in less severe cases because they are convenient and inexpensive for patients who can tolerate oral intake. When pain is severe, analgesics need to be given more urgently and ideally titrated to effect. The intravenous (IV) rather than intramuscular (IM) route is preferred in the ED setting. IM injections are painful, do not allow for titration, have unpredictable absorption, and can result in a slow onset of analgesic effect. Unless IV access is elusive, there are few situations to recommend the IM route. More recently, alternative delivery routes for the administration of pain medications have been described in the ED setting, including nebulized and intranasal fentanyl.

In general, it is inappropriate to delay analgesic use until a diagnosis has been made. In the case of acute abdominal pain, a large number of studies find no deleterious effect of intravenous opioid therapy on the ability of clinicians to make appropriate diagnoses.

Specific Treatment Modalities

A wide variety of analgesics are used in emergency medicine practice. In a 20 ED site survey, a total of 735 doses of 24 different analgesics were administered to 506 patients receiving analgesics while in the ED. The majority of analgesics administered were opioids (59%), with morphine being the most commonly used analgesic (20%), followed by ibuprofen (17%). Since the publication of this study in 2007, however, policy changes have been instituted in an attempt to de-emphasize the use of opioids in response to the opioid epidemic. The rescheduling of hydrocodone from Schedule III to Schedule II, which prevented refills and required a hardcopy prescription, is just one example.