EM...From the IM Prespective

Oligoanalgesia

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A CASE:

A 40 y/o black homeless man presents with difficulty walking secondary to extreme left lower extremity pain. On exam, the patient is afebrile, HR 105, RR 20, BP 120/65. His extremity is swollen, warm, erythematous and extremely tender to touch. A sepsis code is called; the patient is given IVF, vancomycin and cefazolin and admitted to medicine for cellulitis and inability to ambulate. Upon evaluation by the inpatient team, patient is disgruntled and ready to leave AMA, “I came here for leg pain and no one is doing anything!”

The emergency department did a great job of identifying the patient as sepsis and giving fluids and antibiotics, but the patient’s chief complaint of leg pain was never addressed. Maybe he would have been able to ambulate with pain medication. Imagine this was a little old lady who was never able to walk again because those first 24 hours without pain control caused her devastating deconditioning.

OLIGOANALGESIA GALORE

More than 60% of patients seen in the ED have pain as their primary symptom; however, multiple studies have shown that olioganalegesia continues to be a major problem in the ED (1). One retrospective study in an urban academic emergency department showed that only 40% of patients with sickle cell vaso-occlusive crisis, thermal burns or long bone fractures received analgesia! Of those, only 45% had pain meds prescribed at discharge (2). Another study showed 33% of patients who received pain meds were given suboptimal doses (3).

Some might argue that these are retrospective studies and that perhaps half of those patients were refusing pain medications. Argue no more; Knox et al. performed a prospective multicenter study looking at 20 emergency departments. Of 842 patients, only 60% of patients received analgesia (mean wait was 90 minutes). 42% of patients who did not receive pain medication wanted them, but only 31% voiced this desire (4).

Other dissenters may grunt and say, well “oligoanal.. whatever is sad, but that would never happen in my ED. We know how to treat pain.” One pediatric emergency department did show that they knew how to treat pain; in fact, 100% of patients with a vaso-occlusive crisis received pain medication. However, in that same study only 31% of patients with long bone fractures and 26% or patients with thermal burns received any medication for pain (8). It appears that the problem is not whether we know how to treat pain or not, but rather that there are biases that cause us to treat some people’s pain while not treating others.

BARRIERS TO ANALGESIA

Rupp et al. did a wonderful review outlining the inadequate analgesia we provide in emergency medicine. They list many reasons why we do not medicate certain subgroups, citing articles showing that we are poor at providing equal analgesia to various demographics including black, hispanic, elderly, pediatric, men and women patients. Besides demographic biases, why are we not treating people?! Rupp et al. argue that perhaps the observation of pain on a daily basis blunts a physician’s capacity to appreciate pain (5). In an EMRap rant, pain expert Dr. James Ducharme adds that Healthcare workers don’t relate to patient’s pain because they’ve always seen worse. He also comments on the standard eye roll that results from a patient’s pain rating as 9/10, as we think to ourselves “ uh huh.. everyone’s pain is 9/10.” Belittling someone’s pain like this is a result of referral bias; people with low pain scores don’t come to the hospital (9). We only see the people who really have pain! And our job is to treat them… isn’t it?

MYTHS OF PAIN

Myth 1: Pain meds compromise the abdominal exam.

Are you kidding me?! Were you raised by surgeons!? Ok, so most of us don’t still think this way. However, one study showed that while most emergency physicians believe analgesia does not compromise an abdominal exam, the majority still withheld pain medication until after the patient was evaluated by the surgeons (5). Next time you have a patient crying from their surgical abdomen pain, stop and ask yourself, “Am I going to let my fear of conflict with a surgeon cause this poor patient to suffer?”

*If you do get into an argument with the surgeons, remember that early administration of pain medication eliminates the confounder of voluntary guarding, and allows for a better and more accurate exam (10)

Myth 2: Treatment of pain will compromise a patient’s decision making capacity.

Pain and bioethical expert Dr. Gail Van Norman states, “Pain medication should never be withheld from a suffering patient under the guise of obtaining informed consent.” She notes that by withholding medication, the patient may even feel pressure to consent which is just plain unethical. Rupp et al. cite 2 urban ED studies showed that patients who received analgesia were able to maintain their ability to give informed consent. Dr. Norman adds that premedication may even enhance a patient’s ability to consent (5).

Myth 3: Opiophobia: The fear of addiction

Multiple studies have shows that addiction is exceedingly rare in patients treated with opioids for chronic pain (1,5). One review looking at 2507 non-malignancy related chronic pain patients found a calculated abuse/addiction rate of 3.2% even though they were all on chronic opioid therapy (7).

Dr. James Ducharme advises physicians who are really worried about a patient’s addiction potential, to use The Opioid Risk Tool. If a patient is low risk based on this 10 question online calculator, the chance of addiction with chronic opioid use is <1%. Do you have opiophobia when it comes to kids and elderly? Ducharme recommends starting at a low dose and then titrating up (9).

Myth 4: She's not in pain! I just saw her sleeping!

Lastly, were you ever skeptical of the patient you just gave morphine to who was sleeping peacefully until you peaked in and she awoke and told you her pain was unbearable? Don’t be skeptical. More than 90% of ED patients are not pain seeking (1). Ducharme explains that morphine dissociates a patient from pain so they may be able to fall asleep or even separate themself from the pain, but that does not mean the pain is gone or not bothering them. He says, once you decide someone needs pain medication, you should titrate to ‘end of suffering’ (5).

SO HOW CAN WE IMPROVE?

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!

Last: Do not give in to the Great Opiophobia! We are emergency physicians and we aren’t afraid of anything!

 

REFERENCES

  1. Ducharme J. Chapter 38. Acute Pain Management in Adults. In: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011.
  1. Selbst SM, et al. Analgesic use in the emergency department. Ann Emerg Med. 1990; 19: 1010-1013.
  1. Wilson JE et al. Oligoanalgesia in the emergency department. Am J Emerg Med. 1989; 7:620-623.
  1. Knox et al. Pain in the ED: Results of the pain and emergency medicine initiative (PEMI) multicenter study. Journal of Pain. June 2008. Vol 8; 460-466.
  1. Rupp et al. Inadequate Analgesia in Emergency Medicine. Ann. Emerg Med. 2004;43:494-503.
  1. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005 Nov-Dec;6(6):432-42. PubMed PMID: 16336480.
  1. Fishbain DA, Cole B, Lewis J, et al: What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Med9: 444, 2008. PMID 18489635.
  1. Friedland LR et al. Pediatric emergency department analgesic practice. Pediatr Emerg Care. 1997; 13:103-106.
  1. Sachetti M. et al. Community Medicine Rants – Pain Scales. EMRap.org. May 2014. https://www.emrap.org/episode/2014/may/community.
  1. LoVecchio et al. The use of analgesics in patients with abdominal pain. J Emerg Med. 1997 Nov-Dec; 15(6):775-9.

 

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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jshibata

  • Resident Editor-in-chief of blog.clinicalmonster.com
  • Blog author of kchemimage.wordpress.com/category/clinical-radiographs/
  • Co-author of the Resident Journal Review for AAEM’s Common Sense newsletter.
  • EM/IM Resident at Kings County Hospital

2 comments for “Oligoanalgesia”

  1. Ian deSouza
    February 9, 2015 at 6:50 pm

    Nice post! Although we’ve been told by the suits that we do well with timely analgesia, the hospital metrics may falsely overestimate our performance. One way to best use our limited resources is to order pain medication for the patient based on triage. If there is a report of “pain” in their triage on the whiteboard, order some acetaminophen or ibuprofen. Besides treating the patients more quickly, it should also reduce your frequency of work interruptions due to patient complaints. I stay away from reflexively giving ketorolac, as for all patients except renal colic, it has the same analgesic efficacy as ibuprofen, but it takes significantly more nursing time to administer (draw up med, clean site, inject, hemostasis, dispose of sharp, etc.).

  2. Carl
    February 10, 2015 at 4:01 pm

    I think we need to treat most pain immediately as well. I think erroring on the side of one dose of analgesia even for chronic pain people is ok. Pain is a real thing even for those type of suffers. However I think its always think about it a bit when we are giving multiple doses in the ED for something that isn’t acute pain. The treatment for gastroparesis isn’t massive amounts of opioids.

    I always like to have the discussion with patients that these medications don’t take away the pain completely, but make it less prominent.

    Treating Pain is all about the re-evaluation. If someone says they still have pain after you’ve waited enough time for the meds to kick in, re-dose and/or re-think your differential.

    I’d also like to throw a bone out to ketamine and nerve blocks. the 98 year old hip fracture isn’t the one to break out the dilaudid. Ketamine is hemodynamically safe as is lidocaine.

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