Emergency medicine and pain: A topography of influence

Abstract

In this issue of Annals, Rupp and Delaney1Rupp T Delaney KA Inadequate analgesia in emergency medicine.Ann Emerg Med. 2004; 43: 494-503Abstract Full Text Full Text PDF PubMed Scopus (401) Google Scholar 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.2Donovan M Dillon P McGuire L Incidence and characteristics of pain in a sample of medical-surgical inpatients.Pain. 1987; 30: 69-78Abstract Full Text PDF PubMed Scopus (336) Google Scholar, 3Bernabei R Gambassi G Lapane K et al.Management of pain in elderly patients with cancer.SAGE Study Group. Systematic Assessment of Geriatric Drug Use via Epidemiology. JAMA. 1998; 279: 1877-1882Google Scholar, 4Cleeland CS Gonin R Hatfield AK et al.Pain and its treatment in outpatients with metastatic cancer.N Engl J Med. 1994; 330: 592-596Crossref PubMed Scopus (1751) Google Scholar 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).5Green CR Anderson KO Baker TA et al.The unequal burden of pain: confronting racial and ethnic disparities in pain.Pain Med. 2003; 4: 277-294Crossref PubMed Scopus (828) Google Scholar 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).6Anonymous Acute pain management: operative or medical procedures and trauma, Part 1. Agency for Health Care Policy and Research.Clinical Pharmacy. 1992; 11: 309-331PubMed Google Scholar, 7Anonymous Acute pain management: operative or medical procedures and trauma, Part 2. Agency for Health Care Policy and Research.Clinical Pharmacy. 1992; 11: 391-414PubMed Google Scholar, 8American Pain Society Quality of Care Committee Quality improvement guidelines for the treatment of acute pain and cancer pain.JAMA. 1995; 274: 1874-1880Crossref PubMed Scopus (734) Google Scholar 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.9McCaig LF Burt CW National Hospital Ambulatory Medical Care Survey: 2001 emergency department summary.Advance data from vital and health statistics. No. 335. National Center for Health Statistics, Hyattsville, MD2003Google Scholar 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 10-point numeric rating scale), with median overall scores of 8.10Todd KH Sloan EP Chen C et al.Survey of pain etiology, management practices and patient satisfaction in two urban emergency departments.Can J Emerg Med. 2002; 4: 252-256Google Scholar 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 documentation results largely from changes in medical record formats and perhaps mirrors medicine's traditional view of pain as a diagnostic indicator rather than an outcome deserving of attention in its own right. Whether JCAHO standards have yet had an impact on practice is an unanswered question. Nonetheless, any documentation of pain experience is a necessary step in the right direction. The JCAHO initiative is not static, and we look forward to the forthcoming pain management performance measures and standards resulting from these efforts.11Todd KH If you have no destination, any road will do.Acad Emerg Med. 1998; 5: 92-93Crossref PubMed Scopus (1) Google Scholar Thus far, our specialty has been less engaged in the development of pain policy. Although the American College of Emergency Physicians has specific clinical policies addressing abdominal and chest pain, as well as the “Clinical Policy for Procedural Sedation and Analgesia in the Emergency Department,” these policies do not address the general treatment of pain.12American College of Emergency Physicians Clinical policy: critical issues for the initial management and evaluation of patients presenting with a chief complaint of nontraumatic acute abdominal pain.Ann Emerg Med. 2000; 36: 406-415Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar, 13American College of Emergency Physicians Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected acute myocardial infarction or unstable angina.Ann Emerg Med. 2000; 35: 521-544Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar, 14American College of Emergency Physicians Clinical policy for procedural sedation and analgesia in the emergency department.Ann Emerg Med. 1998; 31: 663-677Abstract Full Text Full Text PDF PubMed Scopus (159) Google Scholar Currently, a subcommittee of the Clinical Policies Committee is at work on such a policy statement, and we look forward to its completion and dissemination. Pharmaceutical marketing has a remarkable power to influence our practice. Over the past few years, many pages of Annals' advertising section have touted the supposed benefits of cyclooxygenase-2 selective inhibitors, despite the lack of evidence for their superiority in our patient population over nonselective (and cheaper) nonsteroidal anti-inflammatory drugs. We will continue to be the targets of pharmaceutical houses offering new analgesic agents and delivery systems that may (or may not) represent valuable additions to our analgesic armamentarium. In fact, it is rare that analgesic research leading to US Food and Drug Administration (FDA) approval involves the ED; thus, approved analgesics are tested in patients who may or may not resemble those we treat. To develop analgesics that are effective for ED patients, we must take on the task of promoting research in the ED setting. Results of clinical trials conducted in our departments can then be translated into clinical practice with added confidence. The lack of emergency medicine involvement in the FDA's analgesic regulatory process may have had additional negative consequences. An FDA Advisory Committee addressing the issue of QT prolongation associated with droperidol did not include a representative from our specialty, despite the popularity of this drug among emergency physicians.15Kao LW Kirk MA Evers SJ et al.Droperidol, QT prolongation, and sudden death: what is the evidence?.Ann Emerg Med. 2003; 41: 546-558Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar Likewise, recurrent shortages of drugs, particularly prochlorperazine, fentanyl, and naloxone, have at times adversely affected our analgesic practices. Although these shortages are of unclear and complex provenance, our active, ongoing engagement in the Drug Shortage Program of the FDA's Center for Drug Evaluation and Research will, in the long run, best serve our patients and our colleagues.16Tyler LS Fox ER Caravati EM The challenge of drug shortages for emergency medicine.Ann Emerg Med. 2002; 40: 598-602Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar Regarding education, Rupp and Delaney1Rupp T Delaney KA Inadequate analgesia in emergency medicine.Ann Emerg Med. 2004; 43: 494-503Abstract Full Text Full Text PDF PubMed Scopus (401) Google Scholar note that the Model of the Clinical Practice of Emergency Medicine does not include a formal pain management curriculum. Most medical schools and emergency medicine residencies offer little in the way of pain didactics. Combating this trend through curriculum reform within medical schools and residencies will require time and the development of leadership within our academic training institutions. Given the role that teachers of emergency medicine have increasingly assumed in the early medical school curriculum, we have a tremendous opportunity to shape the attitudes of all future physicians regarding pain treatment, not just those who choose to train in emergency medicine. Given our strategic location in the front lines of patient care and the relative youth of our specialty, we may have particularly pertinent lessons to transmit to medical students regarding pain management practices, with less dogma to obscure a critical examination of current pain management practice. Support for this optimism can be seen in emergency medicine's critical examination of the surgical dictum regarding withholding of opioids from patients with acute abdominal pain. One doubts that in its 20th edition, Cope's Early Diagnosis of the Acute Abdomen17Silen W Cope's Early Diagnosis of the Acute Abdomen. 20th ed. Oxford University Press, New York, NY2000Google Scholar would have undergone the revisions discussed by Dr. Rupp and Dr. Delaney were it not for the research conducted by these investigators. One of emergency medicine's strengths is that it has yet to ossify into a traditional specialty, with rigid, dogmatic conceptions of appropriate pain management practice. Much of our progress in emergency medicine pain research stems from formative work begun 10 years ago by Dr. Jim Ducharme and Dr. William H. Cordell. In 1994, with support from the Canadian Association of Emergency Physicians and the Quebec Association of Emergency Physicians, they convened the First International Symposium on Pain Research in Emergency Medicine in Montreal. This symposium brought together a number of pain researchers in the United States and Canada who subsequently authored 23 articles in the April 1996 issue of Annals addressing pain research standards.18Ducharme J Proceedings from the First International Symposium on Pain Research in Emergency Medicine: foreword.Ann Emerg Med. 1996; 27: 399-403Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar More recently, The Mayday Fund, a New York City–based private foundation, funded grants to the Emergency Medicine Foundation and the American Society for Law, Medicine, and Ethics to help increase our knowledge base and create a forum where medical, legal, and ethical issues related to pain and emergency medicine may be discussed.19The Mayday Fund. Available at: http://www.painandhealth.org/mayday/mayday-home.html. Accessed January 23, 2004Google Scholar In addition, for 2 years, the American Pain Society has sponsored scholarships for emergency physicians to increase our interactions with the broader pain community. These initiatives have provided opportunities and guidance for a growing network of emergency medicine pain researchers. Unfortunately, at the federal level, funding for pain research has lagged behind policy developments. Although pain costs the United States $79 billion annually in lost productivity and results in more than 20% of visits to all physicians and 70% of visits to EDs, only 0.6% of the current National Institutes of Health budget is devoted to basic and clinical pain research.20Stewart WF Ricci JA Chee E et al.Work-related Cost of Pain in the United States: Results From the American Productivity Audit—Abstracts From the Tenth World Congress on Pain. IASP Press, Seattle, WA2002: 224Google Scholar, 21Schappert SM National Ambulatory Medical Care Survey: 1992 summary.Adv Data. 1994; 253: 1-20PubMed Google Scholar, 22Cordell WH Keene KK Giles BK et al.The high prevalence of pain in emergency medical care.Am J Emerg Med. 2002; 20: 165-169Abstract Full Text Full Text PDF PubMed Scopus (379) Google Scholar, 23Max MB How to move pain and symptom research from the margin to the mainstream.J Pain. 2003; 4: 355-360Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar While many factors contribute to the changing of clinical practice, physician leadership has been identified as a dominant component of successful reform efforts.24Bradley EH Holmboe ES Mattera JA et al.A qualitative study of increasing β-blocker use after myocardial infarction: why do some hospitals succeed?.JAMA. 2001; 285: 1604-2611Crossref Scopus (249) Google Scholar Although Donald Berwick once characterized clinical health care leaders as, “… trained to ride out the storm, not to create one,” I believe that our specialty is fundamentally different in this respect.25Berwick DM A user's manual for the IOM's ‘Quality Chasm” report.Health Aff (Millwood). 2002; 21: 80-90Crossref PubMed Scopus (522) Google Scholar Emergency medicine was created in response to the public's demand for high-quality urgent and emergency medical care. Although much remains to be learned in the areas of pain education, research, and policy, strong emergency physician leadership can immediately begin to close the gap between what we know about high-quality pain management and what we actually do. There is a great power in the naming of things. Going forward, we should begin by defining our own standards for excellence in pain practice and promote quality improvement initiatives to achieve these goals. The purpose of this editorial is to help us understand important factors that shape our pain practices. We have explored what we know about this topography of influence, but the most satisfactory method of understanding regions yet to be charted is to create them ourselves. Although we will find many allies in our efforts to ameliorate pain and suffering, the duty to provide superior ED pain management remains our own.