Emergency medicine and pain: A topography of influence

Abstract

In this issue of Annals, Rupp and Delaney1 have done an excellent job of naming the barriers to adequate care of emergency department (ED) patients in pain. Although they paint a somewhat bleak picture for emergency medicine, our specialty is not alone in undertreating pain. Studies have documented oligoanalgesia, the undertreatment of pain, in a variety of patient groups, including medical and surgical inpatients, nursing home residents, cancer patients, and others.2-4 These barriers are common to all medical specialties (inadequate education, lack of institutional commitment) but many are more salient to the emergency medicine community (time demands, lack of patient-physician continuity, diagnostic uncertainty).5 Deficiencies in pain treatment have prompted a number of initiatives to improve the quality of pain management, including practice guidelines from what is now the Agency for Healthcare Research and Quality, quality improvements guidelines from the American Pain Society, and beginning in 2001, revised pain standards from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).6-8 Despite the pessimism that colors this discussion, it is apparent that analgesic practices are evolving rapidly. The latest ED data from the National Hospital Ambulatory Medical Care Survey reveal that, from 1997 through 2001, there has been an impressive 18% increase in analgesic use in US EDs (from 47.2 to 56.2 mentions per 100 visits), with marked increases in both nonsteroidal anti-inflammatory agents and opioid analgesics.9 We do not know the reasons for this increase; however, a number of factors may be at work. These influences include policy and regulatory initiatives, institutional quality improvement programs, pharmaceutical marketing campaigns, educational efforts, and new knowledge from basic and clinical research, among others. This topography of influence is important to understand if we are to move from passive observers to active instigators of change. With regard to policy, this is an active time in the area of pain management. In 2001, the US Congress declared this the “decade of pain control and research,” and JCAHO issued revised standards mandating pain assessment in our EDs. More recently, Congressman Mike Rogers (R-MI) introduced the National Pain Care Policy Act of 2003 (H.R. 1863), another step in the federal recognition of pain as an important health care issue. This bill would create a National Center for Pain and Palliative Care Research at the National Institutes of Health and provide additional funds for pain research and education. In addition, it would create a White House Conference on Pain Care to identify key barriers to high-quality pain management practices and establish a clearinghouse at the Agency for Healthcare Research and Quality to collect and disseminate protocols and evidence-based practices regarding pain to clinicians and the general public. The impact of these policy and regulatory initiatives is difficult to quantify. The revised JCAHO standards have generated some grumblings from emergency physicians about imposed regulations and, in preliminary data from our research efforts, they seem to have prompted increased documentation of pain intensity, although perhaps little else. This documentation reveals that, in general, our patients present with extremely high levels of pain. In one published study, fully half of all patients presenting to the ED with pain experienced pain of severe intensity (8 to 10 on a 10point numeric rating scale), with median overall scores of 8.10 Despite the intention to promote pain intensity as an outcome measure with which to judge the quality of our efforts, our ongoing research finds that pain intensity is measured only once in most EDs, at the time of patient arrival, without additional measures that might reflect the impact of our therapies. This docP A I N M A N A G E M E N T / E D I T O R I A L