Four myths of pain medicine administration
Ethics committees looking for educational resources for pain management now can focus on four myths circulating the halls of most hospitals, especially in emergency departments (EDs). "There is a great deal of ignorance and myth about pain management that ED managers should be aware of," stresses Gregory Henry, MD, FACEP, chief of the department of emergency medicine at Oakwood Hospital-Beyer Center in Ypsilanti, MI. Here are the four myths:
Myth 1: Pain is inevitable. "Because of that attitude, we let a lot of people suffer who don’t need to," Henry says. "Most patients come to the ED because they are hurting. We have so many drugs today to alter perception or memory of pain, and we can take away pain very effectively."
Pain relief is a key part of all therapies, including those that take place in the ED, he emphasizes. "If a patient had bone cancer and had six months left to live, they would be given all the morphine they needed. So why would we not take away pain on a short-term basis?"
Myth 2: Pain medications mask diagnoses. ED physicians typically face roadblocks in managing pain because of fear of masking the diagnosis, particularly in patients with abdominal pain. However, that is changing. "There is an increasing acceptance of relief for patients with abdominal pain, which was such a no-no until about 10 years ago," says Bruce McNulty, MD, medical director of the ED at Ravenswood Hospital in Chicago. "Research shows that we can, in fact, improve diagnostic accuracy by relieving pain."
Still, there is a widespread belief that pain medications may affect the eventual diagnosis, Henry notes. "There is absolutely no evidence that a diagnosis is altered with appropriate use of pain medications. The newer texts now say there is no reason to delay treating pain."
However, some surgeons still may be reluctant to give pain medications, fearing they will obscure a patient’s need for surgery. "If you are seeing a patient with abdominal pain, and the surgeon can’t be there in 10 or 15 minutes, just give a short-acting narcotic, which can easily be reversed," Henry suggests.
Myth 3: Pain medications should be given in small increments. "There is an idea that we need to sneak up on pain, by giving little bits of medication over a period of time, but that’s not the way to treat pain," he says. "The best way is to hit it with high doses and multiple modalities early on."
Many ED clinicians underdose both Tylenol and ibuprofen, says Henry. "A reasonably sized male in good health needs 600 g of Motrin to do anything. The tendency is to use too much medication for too long a period of time, but it’s much better to use a high dose."
Myth 4: Patients may become addicted to narcotics. "Giving three or four days of a narcotic never made anybody an addict," he says. "How ever, this mistaken belief leads to a kind of stoic ethic which makes patients suffer."
There traditionally has been concern about the use of potent narcotic analgesics, especially in children and the elderly, says Emory M. Petrack, MD, MPH, director of the department of pediatric emergency medicine at Rainbow Babies and Children’s Hospital in Cleveland. "ED physicians who do not have significant experience with these populations may feel uncomfortable with the potential side effects related to respiratory or cardiovascular compromise," he says. "The reality is that with some knowledge and experience, it is not difficult to provide good pain relief in the ED."