Equitable pain care
Common mistake is to switch to another analgesic before initial drug sufficiently dosed
(This is the second part of a series on pain management in the emergency department (ED) of a hospital.)
In the ED, the default preference when pain is severe is for intravenous analgesia. Oral pain medication has often been tried at home but takes a long time to work. The intramuscular route is often the easiest, but can cause injection pain, variable speed of onset and difficulty with titration. Although there is less ED experience with intra-nasal or oral transmucosal routes, these approaches hold promise. Rectal analgesia can be useful in treating painful conditions in which nausea and vomiting are prominent.
The initial treatment of acute pain is all too often followed by substantial delay in reassessment and repeat therapy. Lack of familiarity with the principles of ongoing pain treatment can result in increased analgesia requirements and the eventual development of chronic pain.
Pain is easier to prevent than to treat. Frequently, lower total doses of medication are necessary if pain is treated early and appropriately often. This can seem time-consuming but proper pain care actually saves time overall.
Unscheduled return ED visits, bounce-backs, are frequently the result of inadequate post-discharge pain care. When potent analgesia is necessary in the ED, it will likely be necessary for at least a few days after discharge.
The use of multiple drugs, poly-pharmacy, while sometimes helpful, can create a number of problems. Side effects may be compounded when more than one drug is administered. The competing pharmacokinetics of coadministered drugs can make titration very difficult. If pain relief does occur after multiple agents have been administered, it is difficult to know how much each specific drug contributed.
One common mistake is to switch to another analgesic before the initial drug has been sufficiently dosed. Clinicians should give the first-tried drug a fair trial before moving on to another therapy.
Determining how much pain someone has can be very challenging. Patients who can communicate well will tell clinicians how much pain they are having. Children or adults with altered mental status, e.g. dementia, are among those for whom pain assessment gets tricky. Our understanding of “drug-seeking behavior” has made great strides, as has our understanding of the anatomy, physiology, and psychology of addictive behaviors.
The focused history and examination should include, although not overly focus on, red flags, which may indicate drugseeking behavior. Even when inappropriate drug-seeking behavior is not a consideration, physicians are often unable to accurately judge how much pain their patient is experiencing. As a general rule, the patient’s pain is whatever they say it is. Best give the patient the benefit of the doubt.
Pain care needs to be provided equitably to all patient populations, regardless of race, ethnicity, gender, or age. There can sometimes be barriers to this such as language and cultural norms. The adage “treat the patient as if they were your family member” is probably the best guide to clinical decisionmaking.
The extremes of age create special challenges to receiving and delivering pain care. In one study, less than 10 of pediatric patients with long-bone fractures received adequate analgesia during their first hour in the ED. Difficulty getting intravenous access can also be problematic.
Nasal or rectal drug administration is often helpful in younger patients. In older adults, pain assessment can be a problem too, e.g. when there is dementia. Also, older patients are more likely to have side effects. The challenge of geriatric analgesia can often be met by employing opioid-sparing strategies or focused therapies, such as regional nerve blocks for hip fractures.
Overcrowding in the ED is a pervasive problem. One of its many negative consequences is inadequate attention to proper pain care. Pain levels should be automatically re-assessed when checking other vital signs, such as blood pressure, pulse, breathing and level of consciousness.
Patients with chronic pain who take pain meds, particularly opioids, and find themselves in an ED because of pain issues should carry a letter from their treating physician outlining their medical issues and a list of medications which have failed or are being tried currently. One should have attempted to contact their prescribing physician before going to Emergency. Aggressive behavior and confrontations with ED staff are inevitably counter-productive and should be avoided. You should be very clear in communicating your expectations for the ED visit. Be reasonable.