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Research reveals pain problems in ED
Inconsistent pain treatment by clinicians
More education for physicians and research into pain management strategies appropriate to the emergency setting are needed to ensure appropriate care in the emergency department (ED), new research indicates.
Two upcoming studies published in the April issue of the Annals of Emergency Medicine reveal that ED physicians’ prescribing practices vary widely — even when the clinical scenarios are the same.
Researchers at Case Western Reserve University in Cleveland presented different hypothetical clinical scenarios to a group of ED physicians practicing nationwide.1 The study found that ED physicians’ responses to individual pieces of clinical information, such as patients requesting "something strong" for the pain, were highly variable, with at least 10% saying they would be positively influenced by this request and at least 10% of physicians saying they would be negatively influenced by it.
"Pain is the most common reason patients seek emergency department care, and emergency physicians are increasingly viewed as pivotal to improving pain treatment," says Knox H. Todd, MD, MPH, director of the Pain and Emergency Medicine Initiative in Atlanta, which is tasked with building a knowledge base for emergency medicine and creating a forum where medical, legal, and ethical issues related to pain and emergency medicine may be discussed. The initiative is supported by The Mayday Fund, a leading foundation supporting pain treatment efforts.
"It is apparent that pain management practices in emergency medicine are evolving rapidly," Knox adds. "From 1997 to 2001, there has been an impressive 18% increase in analgesic use in U.S. emergency departments, with marked increases in both nonsteroidal anti-inflammatory agents and opioid analgesics. Pain research, such as the articles highlighted here, will help us make improvements in this area more rapidly."
Researchers from the University of Texas Southwestern Medical Center at Dallas report in their review article2 that ED pain management practices need to become more consistent across all demographic groups. The article identifies several areas where improvements could be made, such as intensifying the educational emphasis on pain management in nursing and medical schools, reducing biases held by clinicians in utilizing pain medications, and increasing the number of rigorous studies of populations with special needs that could improve pain management in the ED.
"Going forward, emergency medicine as a specialty should begin by defining its own standards for excellence in pain management and promote quality improvement initiatives to achieve these goals," says Todd. "Although we will find many allies in efforts to relieve pain and suffering, the duty to provide superior emergency department pain management remains our own."
Setting presents unique challenges
Pain management in the ED is difficult because the department presents clinical situations that force physicians to make many treatment decisions without complete information, says Joshua H. Tamayo-Sarver, PhD, a researcher in the Department of Epidemiology and Biostatistics at Case Western Reserve University in Cleveland, OH, and lead author on the first Annals of Emergency Medicine study.
"Much of the information must come from a patient with whom the physician is unfamiliar," he explains. "For painful conditions, where there is little objective evidence of the severity of the pain, the physician must establish sufficient rapport with the patient to determine the severity of the pain, select the most appropriate treatment, and discern the likelihood that opioids are desired for secondary gain."
To evaluate prescribing practices, Tamayo-Sarver and colleagues developed three separate clinical scenarios (a patient with a broken ankle, one with a migraine, and one suffering from back pain), each scenario containing a basic vignette with specific supporting clinical information.
The researchers were trying to select clinical characteristics that might influence a physician to prescribe an opioid analgesic as well as those that could influence a physician to decide against prescribing one.
"We hypothesized that contextual factors would be less important where there were objective clinical findings [an ankle fracture], more important when there were ambiguous indications [migraine], and most important where there are no objective findings [back pain]," he explains. "Second, we also conducted a large secondary data analysis of these conditions in a national data set and our results were consistent with our hypotheses."
But the overall likelihood of the physicians to prescribe an opioid in the situations given showed marked variability with at least 10% of physicians saying they were likely to prescribe, and 10% saying they were unlikely to prescribe for each situation. Physician responses to individual pieces of clinical information, such as the patient requesting "something strong" for the pain, were likely to produce opposite reactions in different physicians, with at least 10% indicating the information would influence them to prescribe and 10% indicating the same piece of information might influence them to decide against it, Tamayo-Sarver notes.
"I think this study demonstrates that ED physicians learn opioid pain prescribing idiosyncratically — there is no uniform approach to pain management," he says. "There was even a good chunk of physicians who used a simple heuristic [I don’t prescribe opioids.’] and none of the information influenced anything. Of note, however, whatever learning process the physicians had varied greatly between physicians, but each individual physician appeared to use the same approach to all three different conditions — despite our hypothesis to the contrary. This suggests to me that physicians informally learn a general approach to pain management at some point in their development, and then apply it to multiple presentations."
Emergency medicine on the front lines’
The study results are disturbing because ED physicians are on the front lines of treating patients in pain, notes Todd.
"The vast majority of patients come to us because of pain problems, and they have very severe pain problems," he says. "People in the primary care setting are often surprised at the level of pain these patients are actually in."
The initiative has done large-scale surveys of patients presenting to EDs and found that more than half present in very severe pain.
"We know ways to measure pain that are reproducible and pretty reliable, and it turns out that fully 50% of patients that come to the ED in pain do so in severe pain," Todd reports. "This includes all patients — the sore throats and very minor sprained ankles, etc. — but 50% feel that they are in severe pain on the order of postoperative pain in terms of severity. These findings are underappreciated by the public and by emergency medicine providers alike."
As in other specialties, emergency medicine physicians are not well trained in managing patients’ pain, Todd says. Medical schools in this country put little effort toward educating their students about appropriate pain management.
"Pain management and analgesic use is almost an afterthought at most medical schools," he says.
That’s not to say good work is not being done, Todd adds. Many ED physicians are willing to aggressively treat pain if they are aware their patients are suffering, and improvements in care are being made.
But, as Tamayo-Sarver indicates, they often are faced with treating patients they don’t know in difficult circumstances. More work needs to be done helping ED physicians determine consistent approaches to pain treatment.
To that end, the initiative is sponsoring research into pain in emergency medicine patients.
"We have already done a few studies, and right now we are embarking on a multicenter study in the United States and Canada that is enrolling patients at anywhere from 20-30 sites in both countries to look at patient pain experience," Todd says. "We want to look at their experience, when they arrive at the ED, how they are treated, [and] how they feel about their experience. Then, we want to follow them up for three months if they still have pain problems, and to see what happened to them."
The Initiative and the American College of Emergency Physicians have entered into dialogues with other specialties and advocates for chronic pain patients to work to improve treatment of pain across the spectrum of care.
1. Tamayo-Sarver JH. Dawson NV, Cydulka RK, et al. Variability in emergency physician decision making about prescribing opioid analgesics. Ann Emerg Med 2004; 43:483-493.
2. Rupp T, Delaney KA. Inadequate analgesia in emergency medicine. Ann Emerg Med 2004; 43:494-496.