Pain Management in the ED: Expert Insights

Between 1996 and 2015, emergency department (ED) visits increased from 90.3 million to 136 million, reflecting a >46% increase.¹ Pain is 1 of the most frequent reasons for ED visits, with 45% to 75% of presentations occurring secondary to pain, and approximately 45% being for moderate or severe pain.^1-3 Adding to the challenge are the diverse patient population and the numerous factors that can cause or contribute to pain, which can be acute and self-limiting or chronic. Regardless of its etiology, when pain is poorly managed in the ED, significant behavioral, physiologic, and/or social issues may arise.² As a consequence, adequate pain management is an essential component of effective ED care.

Analgesics are a cornerstone of pain treatment. When selecting an analgesic, a recent major concern has surrounded the use of opioids. It is estimated that >250 million opioid prescriptions are written annually in the United States, with 91 Americans dying every day from an opioid overdose, and with prescription medications being a contributing factor in these deaths.^4,5 There has been a notion that ED physicians are “handing out opioids like candy.”⁶ However, a study recently published in the Annals of Emergency Medicine disputes this notion.^6,7

Clinical Pain Advisor had the opportunity to discuss this study and the opioid crisis, as well as general pain management principles in the ED, with Howard Mell, MD, a spokesperson for the American College of Emergency Physicians, and a practicing emergency physician in the Chicago area.

Clinical Pain Advisor: As you know, a study by Jeffery and colleagues recently published in the Annals of Emergency Medicine showed that ED physicians are more likely than physicians in other settings to prescribe opioids to opioid-naive patients consistent with the Centers for Disease Control and Prevention’s recommendations for dose, daily supply, and formulation than opioid prescriptions attributed to non-ED settings.⁷ What are your thoughts on these findings?

Dr Mell: Although it is a good, valid study demonstrating that we do have good practices when it comes to opioid prescribing in the ED, I think the results speak more to practice patterns. In the ED, we tend to limit the amount of narcotics patients go home with; we prescribe small amounts because we need the patient to seek follow-up care. Let’s look at a patient with a horribly broken ankle I had to reset. I am obviously going to prescribe a narcotic for the pain, but I am only going to write a 3-day prescription because the patient needs to follow-up with the orthopedic surgeon the next day to have surgery or to have the splint I put on replaced with a formal cast. My typical prescription for narcotics is 7 tablets.

During the past couple of years, as attention to opiate use has increased, we have learned that the duration of use is the key determinant of whether a patient will develop an addiction. The chances of becoming addicted rise dramatically for anyone who uses opioids longer than 7 to 10 days. The orthopedic surgeon or even a family practitioner often sees patients whose pain needs to be controlled for longer than 7 to 10 days. When patients visit a family practitioner for a hip dislocation, for example, they are much more likely to get a prescription for 30 opioid tablets than for 7 tablets, as they would get in the ED. The nature of the practice is probably why the study found people are more likely to become addicted to opioids when they see a non-ED physician vs an ED physician.¹

Clinical Pain Advisor: What are your thoughts on the opioid crisis?

Dr Mell: I think 1 of the biggest drivers of today’s opioid crisis started back in 2001 through 2004 or 2005, when there was a big push to convince everyone that pain is the fifth vital sign and that our goal should be to eliminate all pain at all times. That perspective was practically codified by the Joint Commission, which pushed us to reduce pain levels to a 1 or 0 always. We even developed reimbursement schemes that included the Hospital Consumer Assessment of Healthcare Providers and Systems survey, which asked the patient how well his or her pain was addressed.

During the last couple of years in the ED, however, we have now gone back to flat-out telling people things are going to hurt. “You’ve got a badly sprained ankle, which will get better without surgery. I can give you a powerful nonsteroidal anti-inflammatory drug (NSAID) to take the edge off your pain, but you are going to be uncomfortable for a couple of days, and that is okay. It is the body’s way of keeping you from using that ankle while it heals.” It is okay that the ankle is going to hurt, provided the pain is not agonizing or does not keep the patient from sleeping. The house of medicine is shifting focus to the evidence for pain management with alternatives that have shown better performance in many cases and lower addiction risks; for example, using an NSAID or lidocaine for kidney stones. I am hopeful that the entire house of medicine and the next generation of physicians will start to take the same approach and realize that it is okay to be honest and tell patients it is unrealistic to expect to live a life with no pain. Tell patients they will have days when they wake up and don’t feel great. Stretching or yoga or maybe coffee with a good friend will do a lot more good than stringing them out on a narcotic.

Clinical Pain Advisor: What pain management approaches do you use in the ED?

Dr Mell: There are really 4 approaches to dealing with any painful crisis in the ED or elsewhere. The first is that we can directly address what is causing the pain. For instance, if you have a child with a nursemaid’s elbow, which is when a tendon becomes looped over a bone because the joints are loose at a young age, the easiest thing to do is reduce the nursemaid’s elbow; that is, put the tendon back where it belongs. I had a patient in the ED last night who had a dislocated jaw, which really hurt. The best thing to do for the patient’s pain was to put the jaw back into place.

The next step would be to stop the effects of whatever is going on, and that is where the NSAIDs come in. That would be another way to address pain when we cannot really fix the problem directly. We can stop the effect the problem is having on the body, such as inflammation in the case of a muscle pull, strain, or spasm. We may even use something like lidocaine to literally knock out the sensation of pain the body is having from whatever the problem is. These days, we are using intravenous lidocaine for things like renal colic or pain from kidney stones.

Opiates are, of course, another way to manage pain. Many people believe opiates directly stop pain, but they do not. An opioid releases or mimics endorphins. You still feel pain, but you don’t really care. For example, imagine it is the last play of the Super Bowl and 2 football players (1 from each team) suffer an equally severe break in the same place in the same leg. The football player from the team that just won is still jumping around on that leg, while the player from the team that just lost is lying on the ground in agony. The reason is that when we are very happy, we have endorphins in our body telling us that life is good, and we really do not care as much about pain. Thus, the last approach would be to give you an opioid to address the pain by releasing endorphins so that you do not care.

The final category involves cases of severe pain, especially with ED procedures. In this setting, we can consider sedation and medications such as propofol and ketamine.

Clinical Pain Advisor: If you do have to use an analgesic for acute pain, how would you decide which 1 to select?

Dr Mell: The choice of analgesic depends on what we believe or can prove objectively is causing the pain. Most ED physicians have moved away from administering a narcotic analgesic for strictly subjective pains, where there is no empiric evidence of a medical problem. For example, if someone comes into the ED and says, “Hey, my wrist hurts,” but a physical examination shows no redness or swelling and an X-ray does not show a fracture, most ED physicians are not going to administer a narcotic right away. However, in cases where we have objective evidence of an injury known to be incredibly painful, like a broken femur, we will go straight to narcotics because no amount of NSAIDs, splinting, or anything else is going to relieve that patient’s pain.

Also, certain drugs work very well for specific conditions. We recently learned that patients with kidney stones respond very well to intravenous lidocaine and ketorolac, so we frequently use those for patients we know are experiencing pain from kidney stones, as I previously mentioned. So, in cases where we have a known problem and a medication proven to work well for that problem, we reach for that medication first. Otherwise, our gauge of the pain’s severity, along with our sort of best estimate as to what is going on, helps drive the decision of whether to use a narcotic or an NSAID or to take some other direct action on the problem.

Clinical Pain Advisor: Do you use the same approach for patients who come to the ED with chronic pain?

Dr Mell: One thing that has changed a lot in the ED during the last few years is how we deal with chronic pain. Realistically, most ED physicians try not to treat chronic pain in the ED. In fact, several states now have mandates about treating chronic pain in the ED. For example, Ohio has the Governor’s Cabinet Opiate Action Team, which came out with a series of regulations within the state pharmacy acts that basically say ED physicians are not to treat chronic pain in the ED.

The ED is not intended to treat chronic pain. It exists to assess for and address threats to life or limb, to manage acute problems or acute exacerbations of chronic problems that put someone at risk. There is a real push-pull these days in terms of chronic pain because we certainly care about our patients very much and want them to be comfortable, but it is difficult, at best, to address chronic pain because of the very nature of what it is.

Again, it really comes down to whether the patient has an objective problem. If someone with cancer comes in with chronic pain from worsening bone metastases or someone with sickle cell disease comes in with a painful crisis, most of us ED physicians will allow the patient to guide us in a big way. We will ask them what has worked and how their pain was dealt with in the past, and will most often go with that approach.

We approach them differently than how we approach a patient who comes to the ED with chronic abdominal pain that has been worked up by various specialists, none of whom could find empiric evidence of a problem. In that case, we do not know what we are treating beyond the pain. Now, most of us would say, “I’m very sorry, but you are going to have to see a pain specialist.”

Clinical Pain Advisor: Do you ever have someone come in with pain who does not want any pain medicine?

Dr Mell: Kind of. I think 1 of the bigger challenges lately is when someone comes in who has been successfully treated for opioid addiction. For example, let’s say a recovering opiate addict falls while walking and suffers a broken ankle that we need to reset. Typically, we want to provide a large amount of analgesia so we can manipulate the bone back into place. The patient might say, “Please don’t give me the narcotic because I’m afraid if I get that rush again, I’m going to want more.” Fortunately, we do have alternatives; ketamine comes to mind, which is a dissociative anesthetic that does not produce the same high as opioids.

A lot of ED physicians, myself included, are becoming increasingly adept at using nerve blocks, kind of entering the realm of the anesthesiologist. We will work under ultrasound to block the nerves that lead to the area with the injury. That is also what we commonly do for dental pain, like someone who needs a root canal. Surprisingly, patients often come to the ED with dental pain. We obviously cannot do a root canal, and no amount of NSAID or narcotic is going to work. To stop the patient from caring about the pain, we would have to put him to sleep. What we often do in those cases is use a nerve block and inject bupivacaine into the nerves like the dentist’s office does, numbing up the whole area. The downside is that it is difficult to speak, but the upside is that there is no pain, which is key.

Clinical Pain Advisor: What about patients with drug-seeking behaviors? Are prescription drug monitoring programs effective?

Dr Mell: A great study came out a couple of years ago that basically compared physicians’ opinions before and after looking at a prescription drug monitoring program in the ED. It turned out that it did not change practices much. The study was pretty elegant. Anytime the ED physicians planned to give a patient any type of pain medication, they had to write down what they planned to give, whether it was Vicodin or ibuprofen. Before prescribing, they had to look at the prescription drug monitoring program. Then they would write the prescription. The study showed that ED physicians rarely changed what they planned to do based on the prescription drug monitoring program.

What those programs are very good at are fostering that conversation with somebody about chronic pain. I do not know whether it is as useful at helping us identify the drug seekers as it is at helping us verify what drugs the patient is currently using and forming decisions about what to prescribe for somebody to take home. For any number of societal reasons, patients are not always honest with us about what their pain regimen is at home. That is where I find personal value in the prescription drug monitoring program.

Clinical Pain Advisor: In conclusion, what is your most important message for ED physicians regarding pain management?

Dr Mell: We must take a realistic look at pain. What is causing it and what can we do about it? We need to address the underlying causes first and then do our best to keep patients comfortable with a goal of realistic pain control as opposed to a goal of no pain. As for patients experiencing pain, I do not want them to think they should not bother going to the ED because they will not get any treatment because there are plenty of things we do need to check. I would not want anyone to think we are not interested in treating pain in the ED but, rather, to appreciate that we are interested in addressing the injury or illness that is causing the pain and keeping them not necessarily pain-free but reasonably comfortable.

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References

1. Samcam I, Papa L. Acute pain management in the emergency department. Published May 25, 2016. Accessed October 4, 2017.
2. Chang HY, Daubresse M, Kruszewski SP, Alexander GC. Prevalence and treatment of pain in EDs in the United States, 2000 to 2010. Am J Emerg Med. 2014;32:421-431.
3. Motov SM, Nelson LS. Advanced concepts and controversies in emergency department pain management. Anesthesiol Clin. 2016;34:271-285.
4. Centers for Disease Control and Prevention. Opioid overdose: understanding the epidemic. https://www.cdc.gov/drugoverdose/epidemic/index.html. Updated December 16, 2016. Accessed October 4, 2017.
5. American Society of Addiction Medicine. Opioid addiction 2016 facts & figures. https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf. Accessed October 4, 2017.
6. American College of Emergency Physicians. Patients who get opioids in the ER are less likely to use them [news release]. https://www.prnewswire.com/news-releases/patients-who-get-opioids-in-the-er-are-less-likely-to-use-them-long-term-300524520.html. Released September 26, 2017. Accessed October 4, 2017.
7. Jeffery MM, Hooten WM, Hess EP, et al. Opioid prescribing for opioid-naive patients in emergency departments and other settings: characteristics of prescriptions and association with long-term use [published online September 21, 2017]. Ann Emerg Med. doi: 10.1016/j.annemergmed.2017.08.042