Equitable pain care

Com­mon mis­take is to switch to an­other anal­gesic be­fore ini­tial drug suf­fi­ciently dosed

The Guardian (Charlottetown) - - OPINION - BY DES COLOHAN Des­mond Colohan is a re­tired emer­gency physi­cian and pain spe­cial­ist.

(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.

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