Pain management/original research
Triage Pain Scores and the Desire for and Use of Analgesics

https://doi.org/10.1016/j.annemergmed.2008.04.017Get rights and content

Study objective

Inadequate analgesia (oligoanalgesia) is a common phenomenon. In an effort to improve pain recognition and management, pain scores are mandated by The Joint Commission. When patients with pain do not receive analgesics, treatment is considered deficient. However, the mere presence of pain does not imply that all patients desire analgesics. We determine how often patients in pain desire and receive analgesics in the emergency department (ED). We hypothesize that many ED patients in pain do not desire analgesics and that most who want them receive them.

Methods

We conducted a prospective observational study of pain-related visits to an academic ED during the spring of 2007. Standardized collection of demographic and clinical data was performed, and patients rated their pain severity on a 0 to 10 numeric rating scale. The main outcome measures were the desire for and administration of analgesics during the ED visit. Univariate and multivariate logistic regression was used to identify factors associated with patient desire for and administration of analgesics.

Results

We enrolled 392 patients. Mean (SD) age was 39 years (19), 50% were female patients, 76% were white. Mean (SD) initial pain score was 7.1 (2). Of the 392 patients, 199 (51% [95% confidence interval (CI) 46% to 56%]) desired analgesics and 227 (58% [95% CI 53% to 63%]) received analgesics within 92 (SD 106) minutes. Of patients desiring analgesics, 162 (81% [95% CI 75% to 86%]) received them. Reasons for not wanting analgesics included pain tolerable (47%), analgesic taken at home (11%), and wanting to remain alert (7%). Pain scores were higher in those patients who wanted analgesics than in those patients who did not want analgesics (7.8 [95% CI 7.5 to 8.1] versus 6.4 [95% CI 6.1 to 6.7]; difference 1.4 [95% CI 0.9 to 1.8]). In multivariate analysis, pain scores (odds ratio [OR] 1.3 for every 1-point increase in pain score) and constant pain (OR 2.0) were significant factors that predicted wanting analgesics, whereas pain scores (OR 1.2) and desiring analgesics (OR 7.4) were significant predictors of receiving analgesics.

Conclusion

Nearly half of all ED patients in pain do not desire analgesics and most who desire analgesics receive them. Although the average pain score for patients not wanting analgesics was lower, it was often in the moderate to severe range. Patients should be asked whether they have pain and whether they want analgesics regardless of their pain scores.

Introduction

Inadequate pain management by the medical profession was first reported by 2 psychiatrists in a landmark article in 1973.1 Marks and Sachar,1 who were routinely called on to evaluate drug-seeking behavior and addiction in hospitalized medical patients, concluded that the majority of the patients they examined simply had severe untreated pain. In 1989 Wilson and Pendleton2 coined the term “oligoanalgesia” to represent the failure to recognize or properly treat pain. Since then, multiple studies throughout the world have confirmed the widespread existence of oligoanalgesia in a variety of settings, including long bone fractures, musculoskeletal pain, back pain, migraine, trauma, and burns.3, 4, 5, 6, 7 In fact, studies have shown that as many as 70% of patients with acute painful conditions do not receive any pain medications in the emergency care setting.8

As a result of the focus of national attention on the phenomenon of oligoanalgesia, several major organizations, such as The Joint Commission9 and the Veterans Health Administration10 issued guidelines for evaluating and treating pain. Although several factors have been associated with oligoanalgesia, the inaccurate assessment or lack of assessment of patients' pain is a major predictor of insufficient pain treatment.11 The underestimation of pain by physicians can be circumvented with the use of pain scales.12, 13 Thus, introduction of pain scales has been a major focus of national efforts to reduce oligoanalgesia. A recent study of the National Hospital Ambulatory Medical Care Survey underscores the persistence of oligoanalgesia, especially in minority groups such as blacks and Hispanics.14

Most previous studies have been based on retrospective chart reviews and secondary analyses of large databases that are limited in detail. The phenomenon of oligoanalgesia has generally been interpreted as inhumane, violating the basic needs and rights of patients to receive analgesia. This interpretation is based on the assumption that all patients in pain desire and require analgesics. However, analgesia can only be considered inadequate when there are no contraindications to analgesia and the patient desires analgesics.

We conducted an observational study of emergency department (ED) patients with a painful condition to determine how often patients in pain desire analgesia and receive analgesics while in the ED. We hypothesized that many patients in pain would not desire analgesics and that most patients wanting analgesics would receive them.

Section snippets

Study Design

We conducted a prospective, observational study to determine how frequently patients with painful conditions wanted and received analgesics while in the ED. The study was approved by our institutional review board and all patients gave written informed consent.

Setting

The study was conducted in a suburban academic ED with an affiliated residency in emergency medicine, with an annual ED census of approximately 75,000. There were no standing analgesic protocols or multidisciplinary quality improvement

Results

During the study period, we enrolled 392 patients. Study patient and pain characteristics are presented in Table 1. Of all patients, 39% had already taken some form of an analgesic at home.

Of the 392 study patients, 199 (51% [95% CI 46% to 56%]) stated that they desired analgesics while in the ED. The most common reasons for not wanting analgesics included the feeling that the pain was tolerable (47%), analgesics were already taken at home (11%), and the concern that receiving analgesics would

Limitations

Our study has several notable limitations. First, it is limited to a single, suburban, mostly English-speaking, affluent setting. As such, our results may not generalize to other dissimilar settings. This may be particularly relevant in evaluation of the effects of race and ethnicity on our results. Lack of a detectable significant difference among races and ethnic groups may be due to small subgroup sample size. This is especially pertinent because previous studies suggest higher rates of

Discussion

Pain is one of the most common ailments afflicting humans. The importance of timely recognition and treatment of pain cannot be overemphasized. Not only is it the right thing to do but also early management of pain may help reduce the likelihood of an exaggerated inflammatory and stress response, may prevent intensification of the pain caused by a “windup” phenomenon, prevent long-term chronic pain and dysesthesias, and reduce the likelihood of the posttraumatic stress disorder.17, 18, 19

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  • Cited by (0)

    Supervising editor: Knox H. Todd, MD, MPH

    Author contributions: AJS and CD conceived the study and designed the trial. AJS and GG supervised the conduct of the trial and data collection. JKC and CD undertook recruitment of patients. AJS and HCT managed the data, and HCT provided statistical advice on study design and analyzed the data. AJS and GG drafted the article, and all authors contributed substantially to its revision. AJS takes responsibility for the paper as a whole.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.

    Publication dates: Available online May 23, 2008.

    Reprints not available from the authors.

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