Pain-related Complaints Research Articles

Patient anxiety may influence the efficacy of ED pain management

ObjectiveThe aim of this study was to evaluate the incidence of anxiety and rates of anxiety treatment in emergency department (ED) patients presenting with pain-related complaints. MethodsWe prospectively evaluated patients in an urban academic tertiary care hospital ED from 2000 through 2010. We enrolled a convenience sample of adult patients presenting with pain and recorded patient complaint, medication administration, satisfaction, and pain and anxiety scores throughout their stay. We stratified patients into 4 different groups according to anxiety score at presentation (0, none; 1-4, mild; 5-7, moderate; 8-10, severe). ResultsWe enrolled 10 664 ED patients presenting with pain-related complaints. Patients reporting anxiety were as follows: 25.7%, none; 26.1%, mild; 23.7%, moderate; and 24.5%, severe. Although 48% of patients described moderate to severe anxiety at ED presentation and 60% were willing to take a medication for anxiety, only 1% received anxiety treatment. Thirty-five percent of patients still reported moderate/severe anxiety at discharge. Severe anxiety at ED presentation was associated with increased demand for pain medication (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.10-1.79) and anxiety medication (OR, 4.34; 95% CI, 3.68-5.11) during the ED stay and decreased satisfaction with the treatment of pain (β coefficient = −0.328; P < .001). After adjusting for age, sex, and presentation pain scores, patients who reported severe anxiety were more likely to receive an analgesic (OR, 1.33; 95% CI, 1.19-1.50) and an opioid (OR, 1.25; 95% CI, 1.11-1.41) during the ED stay. ConclusionAnxiety may be underrecognized and undertreated in patients presenting with pain-related complaints. Patients reporting severe anxiety were less likely to report satisfaction with the treatment of their pain, despite higher rates of analgesic administration.

Geriatric Patients May Not Experience Increased Risk of Oligoanalgesia in the Emergency Department

The aim of this study is to compare the pain management practices in geriatric patients in the emergency department (ED) with that in other adult ED patients to determine whether these patients face increased risk of oligoanalgesia. This study was a prospective analysis of a convenience sample of patients presenting to an urban academic tertiary care hospital ED from 2000 through 2010. We compared patients aged 65 years and older (geriatric) with adults younger than 65 years and evaluated analgesic administration rates, opioid administration and dosing, and pain and satisfaction scores (0 to 10 scale). A total of 15,387 patients presented to the ED during the 10-year study period and agreed to participate in the study; 1,169 patients were geriatric (7.6%). Geriatric patients had a mean age of 75.0 years (SD 7.2 years), whereas mean age of the 14,218 nongeriatric patients was 35.5 years (SD 12.2 years). Geriatric patients reported less pain at presentation (6.2 versus 6.9). After adjusting for presentation pain scores, geriatric patients were not less likely to receive an analgesic during the ED visit (odds ratio 0.90; 95% confidence interval 0.78 to 1.05) or less likely to receive an opioid (odds ratio 1.01; 95% confidence interval 0.87 to 1.18). Geriatric patients, on average, received lower doses of morphine (3.3 versus 4.2 mg) and had longer waiting times for their initial dose of an analgesic medication (65 versus 75 minutes). Despite longer wait times for analgesia, geriatric and nongeriatric patients were similar in rates of analgesia and opioid administration for pain-related complaints. These findings contrast with previous studies reporting lower rates of analgesia administration among geriatric patients.

Prospective evaluation of the treatment of pain in the ED using computerized physician order entry

BackgroundTreatment of pain in the emergency department (ED) is a significant area of focus, as previous studies have noted generally inadequate treatment of pain in ED patients. Previous studies have not evaluated the impact of computerized physician order entry (CPOE) on the treatment of pain in the ED. We sought to evaluate treatment of pain before and after implementation of CPOE in an academic ED. MethodsWe prospectively enrolled a convenience sample of patients presenting to the ED with a pain-related complaint in 4-month periods before and after CPOE implementation. We compared numbers who received pain medications, time from registration to administration of pain medication, and repeat dosing of pain medication. ResultsSix hundred forty-six ED patients participated in the pre-CPOE period, whereas 592 patients participated post-CPOE. Similar numbers of patients received pain medications in the pre-CPOE and post-CPOE periods (55% vs 59%; P = .139), whereas those in the post-CPOE period were more likely to receive a repeat dose of pain medications (10.5% vs 17.6%; P < .001). ConclusionThe use of CPOE in the ED may offer modest benefits in the treatment of patients with pain-related complaints.

Pain Care Management in the Emergency Department: A Retrospective Study to Examine One Program's Effectiveness

No clear consensus exists regarding the most appropriate approach to reducing repetitive ED visits for pain complaints. These visits create a burden on health care resources and may contribute to inappropriate and excessive use of opioid medications. The purpose of this study was to examine the pain management program in 1 emergency department (1) to determine whether ED visits significantly decreased among program enrollees; (2) to quantify program interventions applied to enrollees; and (3) to explore relationships between enrollee characteristics (sex, age, comorbidities, health coverage plans) and the program's interventions and outcomes. A retrospective, descriptive, correlational design was used to examine the medical records of 134 patients who were enrolled in a pain care management program during a 1-year period. Study subjects' ED visits were reduced by 77%, from 3,689 total visits during the pre-enrollment year to 852 in the post-enrollment year (P < .001). As a result of the program, patients were referred to primary care providers (58%), addiction specialists (14%), dentists (4%), neurosurgeons (4%), and neurologists (4%). The most common pain management program interventions were narcotic restriction (65%), establishment of a non-narcotic treatment regimen (57%), and enactment of a "1 pharmacy/1 provider" restriction (23%). This study supports existing evidence that patients with an excessive number of ED visits for pain-related complaints can be managed with a proactive pain care management program that includes coordination with a primary care provider and a supportive ED medical staff.

Frequent Users of Emergency Department Services: Gaps in Knowledge and a Proposed Research Agenda

Frequent use of emergency department (ED) services is often perceived to be a potentially preventable misuse of resources. The underlying assumption is that similar and more appropriate care can be delivered outside of EDs at a lower cost. To reduce costs and incentivize more appropriate use of services, there have been efforts to design interventions to transition health care utilization of frequent users from EDs to other settings such as outpatient clinics. Many of these efforts have succeeded in smaller trials, but wider use remains elusive for varying reasons. There are also some fundamental problems with the assumption that all or even the majority of frequent ED use is misuse and invoking reasons for that excessive use. These tenuous assumptions become evident when frequent users as a group are compared to less frequent users. Specifically, frequent users tend to have high levels of frequent ED use, have a higher severity of illness, be older, have fewer personal resources, be chronically ill, present for pain-related complaints, and have government insurance (Medicare or Medicaid). Because of the unique characteristics of the population of frequent users, we propose a research agenda that aims to increase the understanding of frequent ED use, by: 1) creating an accepted categorization system for frequent users, 2) predicting which patients are at risk for becoming or remaining frequent users, 3) implementing both ED- and non-ED-based interventions, and 4) conducting qualitative studies of frequent ED users to explore reasons and identify factors that are subject to intervention and explore specific differences among populations by condition, such as mental illness and heart failure.

ED Pain Management Program Hinders Drug-Seeking

ED Pain Management Program Hinders Drug-Seeking

Multiple Pain Complaints in Patients With Major Depressive Disorder

To characterize the co-existence of multiple pain-related complaints in patients enrolled in a series of pharmaceutical company drug trials for the treatment of Major Depressive Disorder (MDD). Pooled 'blinded' data from 2191 patients enrolled in randomized, multicenter, double-blind placebo-controlled studies for the treatment of MDD were analyzed. Painful symptoms were assessed using the seven pain symptoms subset of the Somatic Symptoms Inventory: 'Headache,' 'Pain in lower back,' 'Neck pain,' 'Pain in joints,' 'Soreness in muscles,' 'Pain in heart or chest,' and 'Pain or cramps in abdomen.' The 17-item Hamilton Depression Rating Scale (HAMD) was used to assess severity of depression. Of those meeting the study entry criteria (total HAMD score >or=15), 25% reported no pain complaints and 18% reported 1 pain compliant; the majority (57%) of patients reported the co-existence of multiple pain-related complaints, with 14%, 12%, 11%, 11%, 7%, and 3% of patients reporting 2, 3, 4, 5, 6 and 7 different pain symptoms, respectively. The number of pain-related symptoms experienced was moderately related to severity of depression (r = 0.35), with the most common pain symptom combinations being among headaches, lower back pain, neck pain, pain in joints, and soreness in muscles. This study supports pain as a component feature of MDD. The number of comorbid pain-related complaints, which generally increased as a function of depressive severity, should be considered in the diagnosis of depression, planning of treatment strategies, and measurement of treatment outcome.

Effectiveness of nonnarcotic protocol for the treatment of acute exacerbations of chronic nonmalignant pain

Introduction Emergency department (ED) overcrowding is a growing problem. Frequent visits for chronic pain are a significant subset of patients. The use of narcotics in these patients is controversial. The purpose of this study was to test a strict nonnarcotic protocol in reducing need for and number of ED visits for chronic pain while at the same time addressing their pain. Methods This was a prospective observational study. We identified patients with more than 10 ED visits for exacerbations of chronic nonmalignant pain in the last 12 calendar months. Each patient and their physician were sent letters informing them of the concern of frequent ED use and the use of opioids for rescue therapy. Furthermore, the patient would receive medications other than narcotics in subsequent ED visits, and follow-up with the primary physician for alternatives was encouraged. Use of the ED for pain-related visits was then monitored for the subsequent 12-month period. Clinic use and outpatient medication uses were also monitored. Results Fifteen patients were identified for the initial study. These patients averaged 19 ED visits per 12 months for pain-related complaints. All of them had a regular physician. After notification of the new protocol, ED visits decreased to an average of 2 visits per year. Visits with primary care physicians also dropped from an average of 19 visits per year to 7 visits. There were 7 patients who had been weaned off narcotic medications, 4 who had been converted to methadone maintenance, and 1 who had been switched to a fentanyl patch. Conclusions Initiation of a strict nonnarcotic protocol for treatment of patients with frequent ED visits for chronic nonmalignant pain results in a significant drop in the number of pain-related visits to the ED. These visits were not offset by a significant elevation in the number of clinic visits for pain complaints, and many were weaned off narcotics. Nonnarcotic protocols for acute exacerbations of chronic nonmalignant pain may be a viable alternative for reducing frequent pain-related ED visits in a select population.

Pain-related comorbidity in depression: the association with 5-HTTLPR and STin2

Background Response to selective serotonin reuptake inhibitors (SSRIs) in major depressive disorder has been suggested to be influenced by variations in the serotonin transporter gene (such as 5-HTTLPR and STin2) [1-3]. In addition, the presence of concomitant physical complaints, particularly pain-related complaints, also increases the risk on SSRI non-response [4]. Since the serotonin transporter is thought to be involved in pain development, an observed association between serotonin transporter genotype and SSRI non-response could be partially due to mediation of the risk of comorbidity in depression. This study evaluates the association between the presence of comorbidity (with or without pain) and serotonin transporter genotype in major depressive disorder.

Pain in the Emergency Department

Although 78% of emergency department (ED) patients present with a pain-related complaint, few published studies address treating, rather than diagnosing, this complaint. This study correlated initial, discharge and post-discharge ED pain assessments, and examined ED pain management and potential treatment barriers. Objectives: To examine the correlation of patient, accompanying adult, nurse and physician pain assessments; determine the characteristics of patients presenting with pain; evaluate the effectiveness of ED pain intervention.

Pain in women: Tender point examination in women with vulvar vestibulitis syndrome: Evidence for generalized and heightened pain sensitivity to manual palpation

Vulvar vestibulitis syndrome (VVS) is a common cause of painful intercourse, affecting up to 12% of pre-menopausal women in the general population. In addition to recent evidence pointing to the importance of peripheral processes involved in the development and maintenance of VVS (e.g., increase in innervation), emerging data indicate that the central nervous system may also be involved: women with VVS report more pain-related complaints and have lower non-genital tactile, pain, and pressure thresholds than non-affected women. The primary goal of the present study was to examine whether women with VVS are more sensitive to pressure in non-genital areas of the body than control women. To date, 6 women with VVS and 12 control participants (mean age 25) underwent a standardized physical examination typically used for the diagnosis of fibromyalgia. An experienced, blinded rheumatologist manually palpated 9 non-genital body locations bilaterally (including left and right gluteal, low cervical, and supraspinatus regions). Pain intensity and unpleasantness ratings were recorded on a scale from 0 to 10. Intensity and unpleasantness ratings were not significantly different for the left and right sides of any given area; therefore, measures from left and right sides were averaged for each site. Analyses of variance (Bonferroni corrected for multiple comparisons) indicated that women with VVS rated both pain intensity and unpleasantness significantly higher than control women at every site examined (all p's < 0.05). The same pattern of results held when analyses were restricted to 6 VVS-control pairs matched on age and oral contraceptive use. Women with VVS reported significantly higher pain intensity and unpleasantness ratings in response to palpation to various non-genital body regions than control participants. These results are consistent with the idea that women with VVS may suffer from a more generalized sensory abnormality than is currently believed.

Childhood sexual abuse, psychological distress, and medical use among women.

This study examined the relationships between reported history of childhood sexual abuse (CSA), psychological distress, and medical utilization among women in a health maintenance organization (HMO) setting. Participants were 206 women aged 20 to 63 years who were recruited from an HMO primary care clinic waiting area. Participants were classified, using screening questionnaires and the revised Symptom Checklist 90, as 1) CSA-distressed, 2) distressed only, 3) CSA only, or 4) control participants. Medical utilization rates were generated from the computerized database of the HMO for 1) nonpsychiatric outpatient, 2) psychiatric outpatient, 3) emergency room (ER), and 4) inpatient admissions. CSA-distressed and distressed only groups both used significantly more nonpsychiatric outpatient visits than CSA only and control participants but were not different from one another. CSA only and control participants did not differ on nonpsychiatric outpatient utilization. CSA-distressed participants used significantly more ER visits and were more likely to visit the ER for pain-related complaints than other participants. Among CSA-distressed participants, those who met criteria for physical abuse had significantly more ER visits than those who did not. There were no differences among the four groups in inpatient utilization rates. Psychological distress is associated with higher outpatient medical utilization, independent of CSA history. History of CSA with concomitant psychological distress is associated with significantly higher ER visits, particularly for those with a history of physical abuse. History of CSA without distress is not associated with elevated rates of medical utilization. Screening for psychological distress, CSA, and physical abuse may help to identify distinct subgroups with unique utilization patterns.