Causes and Consequences of Inadequate Management of Acute Pain

Improving acute pain management in emergency medicine

Undertreatment of pain (oligoanalgesia) in the emergency department is common, and it negatively impacts patient care. Both failure of appropriate pain assessment and the potential for unsafe analgesic use contribute to the problem. As a result, achieving satisfactory analgesia while minimizing side effects remains particularly challenging for emergency physicians, both in the emergency department and after a patient is discharged. Improvements in rapid pain assessment and in evaluation of noncommunicative populations may result in a better estimation of which patients require analgesia and how much pain is present. New formulations of available treatments, such as rapidly absorbed, topical, or intranasal nonsteroidal anti-inflammatory drug formulations or intranasal opioids, may provide effective analgesia with an improved risk-benefit profile. Other pharmacological therapies have been shown to be effective for certain pain modalities, such as the use of antidepressants for musculoskeletal pain, γ-aminobutyric acid agonists for neuropathic and postsurgical pain, antipsychotics for headache, and topical capsaicin for neuropathic pain. Nonpharmacological methods of pain control include the use of electrical stimulation, relaxation therapies, psychosocial/manipulative therapies, and acupuncture. Tailoring of available treatment options to specific pain modalities, as well as improvements in pain assessment, treatment options, and formulations, may improve pain control in the emergency department setting and beyond.

Pain management in the emergency chain: the use and effectiveness of pain management in patients with acute musculoskeletal pain

OBJECTIVE

While acute musculoskeletal pain is a frequent complaint in emergency care, its management is often neglected, placing patients at risk for insufficient pain relief. Our aim is to investigate how often pain management is provided in the prehospital phase and emergency department (ED) and how this affects pain relief. A secondary goal is to identify prognostic factors for clinically relevant pain relief.

DESIGN

This prospective study (PROTACT) includes 697 patients admitted to ED with musculoskeletal extremity injury. Data regarding pain, injury, and pain management were collected using questionnaires and registries.

RESULTS

Although 39.9% of the patients used analgesics in the prehospital phase, most patients arrived at the ED with severe pain. Despite the high pain prevalence in the ED, only 35.7% of the patients received analgesics and 12.5% received adequate analgesic pain management. More than two-third of the patients still had moderate to severe pain at discharge. Clinically relevant pain relief was achieved in only 19.7% of the patients. Pain relief in the ED was higher in patients who received analgesics compared with those who did not. Besides analgesics, the type of injury and pain intensity on admission were associated with pain relief.

CONCLUSIONS

There is still room for improvement of musculoskeletal pain management in the chain of emergency care. A high percentage of patients were discharged with unacceptable pain levels. The use of multimodal pain management or the implementation of a pain management protocol might be useful methods to optimize pain relief. Additional research in these areas is needed.

The pain experience of inpatients in a teaching hospital: revisiting a strategic priority

For hospital executives and clinicians to improve pain management, organizations must examine the current pain experience of in-patients beyond simply measuring patient satisfaction. The aim of this study was to quantify the prevalence of pain among adult in-patients and the degree of interference pain had on daily activities. A descriptive, cross-sectional study was undertaken in a 530 bed tertiary care, teaching hospital in central Canada. A convenience sample (N = 88) of adult medical-surgical patients completed the Short Form-Brief Pain Inventory survey. Pain prevalence was 70.4%. The mean pain severity score was 3.76 (standard deviation, SD = 2.88) and mean pain interference score on daily activities was 4.56 (SD = 3.93). The most frequently identified site of pain was the lower extremities (n = 15, 28%). Women had higher mean scores on pain "right now" compared to men (p < 0.05). The sample majority (n = 81) indicated hospital staff asked about the presence of pain. Seventy-nine percent (n = 57) reported hospital staff "always" did everything they could to help manage pain. Eighty-four percent (n = 61) selected "always" or "usually" to describe their ability to be involved in deciding pain treatments. The mean pain relief score from treatments was 61% (SD = 34.79). Significant positive correlations were found between pain intensity ratings and pain interference on all daily activities (p < 0.001). Pain prevalence remains high with a significant relationship between pain and activities of daily living. The study provides baseline data to direct future initiatives at improving pain management.

A review of the literature on multiple factors involved in postoperative pain course and duration

OBJECTIVE

To review the literature on the progression from acute to chronic postoperative pain, to evaluate the evidence for the risk of progressing to persistent postoperative and chronic pain, and to identify characteristics of pharmacologic treatments to best tailor therapy to an individual patient's pain profile.

BACKGROUND

Pain is most commonly classified by duration (acute, chronic) and pathophysiology (nociceptive, neuropathic); however, these descriptors alone incompletely describe pain. Additionally, the transition between acute and chronic postoperative pain is not well understood.

METHODS

We conducted a qualitative review and evaluation of the literature on postoperative pain with respect to the above objectives.

RESULTS

Individualized pharmacologic treatments require a complete characterization of a patient's pain profile, in terms of frequency of pain over the course of a 24-hour day and over time thereafter, frequency and duration of pain flares, and presence of neuropathic pain. These considerations can help guide the choice of pharmacologic treatment to meet patient needs over a 24-hour day and over time after surgery. With respect to opioid analgesics, acute pain requires rapid onset of analgesia and the ability to titrate analgesia to the changing characteristics of pain over a short period. For these reasons, short-acting opioid analgesics have been preferred; however, there are opioid formulations with rapid onset and extended release for reduced dosing frequency. Although nociceptive pain can typically be controlled by titration of the dose of an opioid analgesic, neuropathic pain may respond better to the addition of an antineuropathic medication rather than to opioid dose escalation.

CONCLUSION

Advances in individualized pharmacologic treatment for postoperative pain have resulted in better pain control. Moreover, the recognition of sub-acute pain as a new entity is important because many surgical patients will need therapy beyond the first 8 days after surgery. In this group of patients the diagnosis of a neuropathic pain component will be important so that appropriate multimodal therapy may be implemented.

Is adequate pain relief and time to analgesia associated with emergency department length of stay? A retrospective study

OBJECTIVES

Evaluate the association of adequate analgesia and time to analgesia with emergency department (ED) length of stay (LOS).

SETTING AND DESIGN

Post hoc analysis of real-time archived data.

PARTICIPANTS

We included all consecutive ED patients ≥18 years with pain intensity >6 (verbal numerical scale from 0 to 10), assigned to an ED bed, and whose pain was re-evaluated less than 1 h after receiving analgesic treatment.

OUTCOME MEASURES

The main outcome was ED-LOS in patients who had adequate pain relief (AR=↓50% pain intensity) compared with those who did not have such relief (NR).

RESULTS

A total of 2033 patients (mean age 49.5 years; 51% men) met our inclusion criteria; 58.3% were discharged, and 41.7% were admitted. Among patients discharged or admitted, there was no significant difference in ED-LOS between those with AR (median (25th-75th centile): 9.6 h (6.3-14.8) and 18.2 h (11.6-25.7), respectively) and NR (median (25th-75th centile): 9.6 h (6.6-16.0) and 17.4 h (11.3-26.5), respectively). After controlling for confounding factors, rapid time to analgesia (not AR) was associated with shorter ED-LOS of discharged and admitted patients (p<0.001 and <0.05, respectively). When adjusting for confounding variables, ED-LOS is shortened by 2 h (95% CI 1.1 to 2.8) when delay to receive analgesic is <90 min compared with >90 min for discharged and by 2.3 h (95% CI 0.17 to 4.4) for admitted patients.

CONCLUSIONS

In our study, AR was not linked with short ED-LOS. However, rapid administration of analgesia was associated with short ED-LOS.

A randomized, double-blind, placebo-controlled study of the efficacy and safety of MNK-795, a dual-layer, biphasic, immediate-release and extended-release combination analgesic for acute pain

OBJECTIVE

To investigate the efficacy and safety of a bilayer combination oxycodone (OC) and acetaminophen (APAP) analgesic with both immediate-release and extended-release (ER) components (OC/APAP ER) in patients with moderate to severe pain using an established acute pain model.

RESEARCH DESIGN AND METHODS

This was a randomized, double-blind, placebo-controlled trial. Adult patients were included in the study if they had a pain intensity score≥4 on a 0-10 numerical rating scale after bunionectomy surgery, and were randomized (1:1) to receive four doses (two tablets q12h) of OC/APAP ER or placebo.

CLINICAL TRIAL REGISTRATION

NCT01484652.

MAIN OUTCOME MEASURES

The primary efficacy endpoint was the summed pain intensity difference over the first 48 hours (SPID48). Secondary endpoints included SPIDs and total pain relief (TOTPAR) over the dosing intervals; time to perceptible, meaningful, and confirmed pain relief; and the proportion of patients with ≥30% reduction in pain intensity scores.

RESULTS

A total of 329 patients were enrolled, of whom 266 (OC/APAP ER, n=135; placebo, n=131) completed the study. The mean (SE) SPID48 was 114.9 (7.6) in the OC/APAP ER group and 66.9 (7.6) in the placebo group (P<0.0001). SPID and TOTPAR values were significantly greater with OC/APAP ER than with placebo over all time periods analyzed, and the median times to perceptible, meaningful, and confirmed pain relief were significantly shorter. More patients showed ≥30% reduction in pain intensity scores with OC/APAP ER than with placebo at all times after 0.5 hours. OC/APAP ER was generally well tolerated. A limitation of this study was the lack of an active comparator.

CONCLUSIONS

OC/APAP ER was efficacious and generally well tolerated in an established model of moderate to severe acute pain, providing an onset of analgesia in approximately 30 minutes and sustained pain relief over the 12 hour dosing period.

Tamper-resistant opioid formulations in the treatment of acute pain

INTRODUCTION

Pain-including acute or persistent acute pain-is a common condition that is increasingly being treated with opioids in the United States. The acute pain treatment setting may represent a key target for addressing the growing epidemic of prescription drug abuse occurring hand in hand with the rise in opioid prescribing. Balancing the needs of pain treatment with abuse prevention can be challenging for clinicians.

METHODS

This article identified efforts to balance opioid abuse risks with opioid availability through the extensive experience of the author in this field. In addition, PubMed literature searches using terms such as "prescription opioid abuse", "abuse-deterrent opioids", and "tamper-resistant opioids"; and inspection of the bibliographies of relevant articles were used to identify relevant sources.

RESULTS

These multifaceted efforts have included: improving assessment of patient risk for drug misuse, abuse, or diversion; funding of and encouraging referral to addiction treatment programs; access to and widespread use of prescription monitoring programs (PMPs); public knowledge of prescription opioid abuse; proper storage of opioid medications; and development of new formulations designed to resist tampering and deter abuse. This review discusses the problem of prescription opioid abuse and strategies to minimize risk within the context of acute pain treatment, and explores the potential role of tamper-resistant opioid formulations and other abuse deterrence strategies in the area of acute or persistent acute pain management.

CONCLUSION

In order to stem the tide of prescription opioid abuse and preserve the availability of opioids as a much needed analgesic option, a multifaceted approach that includes tamper-resistant opioid formulations-for chronic or acute pain-along with strategies such as improved patient risk assessment, funding for and referral to addiction treatment programs, greater use of PMPs, and raised awareness of prescription opioid abuse is needed.

Improving undergraduate medical education about pain assessment and management: a qualitative descriptive study of stakeholders' perceptions

BACKGROUND

Pain is one of the most common reasons for individuals to seek medical advice, yet it remains poorly managed. One of the main reasons that poor pain management persists is the lack of adequate knowledge and skills of practicing clinicians, which stems from a perceived lack of pain education during the training of undergraduate medical students.

OBJECTIVE

To identify gaps in knowledge with respect to pain management as perceived by students, patients and educators.

METHODS

A qualitative descriptive study was conducted. Data were generated through six focus groups with second- and fourth-year medical students, four focus groups with patients and individual semistructured interviews with nine educators. All interviews were audiotaped and an inductive thematic analysis was performed.

RESULTS

A total of 70 individuals participated in the present study. Five main themes were identified: assessment of physical and psychosocial aspects of pain; clinical management of pain with pharmacology and alternative therapies; communication and the development of a good therapeutic relationship; ethical considerations surrounding pain; and institutional context of medical education about pain.

CONCLUSION

Participating patients, students and pain experts recognized a need for additional medical education about pain assessment and management. Educational approaches need to teach students to gather appropriate information about pain, to acquire knowledge of a broad spectrum of therapeutic options, to develop a mutual, trusting relationship with patients and to become aware of their own biases and prejudice toward patients with pain. The results of the present study should be used to develop and enhance existing pain curricula content.

The role of the emergency department in the acute management of chronic or recurrent pain

BACKGROUND

Exacerbation of chronic pain is a common presenting problem for patients attending emergency departments (EDs), with many making multiple visits.

AIM

This paper aims to identify the role of the ED in the acute management of patients with persistent or chronic nonmalignant pain through a review of current literature.

METHOD

Four databases were searched using the MeSH and subject search terms "chronic nonmalignant pain", "persistent pain" and "emergency" and synonyms associated with these terms. Literature related to the underlying causes of suboptimal chronic pain management along with the sequelae associated with treatment or management was extracted.

RESULTS

Three main themes emerged: patient expectations and satisfaction, barriers to care, and strategies/principles to improve ED management for this patient group. The presence of these themes appears to be partially due to time limitations for chronic issues in an acute department, accompanied by a lack of clear guidelines.

CONCLUSION

It is evident that the ED is not the ideal setting for managing patients with chronic pain however it is the last resort for many who do present, and who will continue to present should their pain persist. It is time to ensure that the ED provides a consistently supportive, cohesive and integrated approach to managing patients with chronic pain syndromes.

Pre-anaesthesia residency requirements: what provides a solid foundation?

The specialty of anaesthesiology has expanded from the intra-operative management of the surgical patient undergoing an operative procedure to the perioperative management of patients undergoing procedures. The perioperative management involves the preoperative evaluation and preparation and also involves the postoperative management of the patient. To effectively perform these functions, a solid foundation in cardiology, pulmonary Medicine, critical care Medicine and pain medicine is mandatory. After completing the required courses in medical school, electives in these areas will prepare the student for further training in anaesthesiology.

Prevention of chronic pain after surgical nerve injury: amputation and thoracotomy

Although techniques for acute pain management have improved in recent years, a dramatic reduction in the incidence and severity of chronic pain following surgery has not occurred. Amputation and thoracotomy, although technically different, share the commonalities of unavoidable nerve injury and the frequent presence of persistent postsurgical neuropathic pain. The authors review the risk factors for the development of chronic pain following these surgeries and the current evidence that supports analgesic interventions. The inconclusive results from many preemptive analgesic studies may require us to reconceptualize the perioperative treatment period as a time of gradual neurologic remodeling.