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Pain management in the Emergency Department – Still a long way to go?

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Published/Copyright: October 1, 2016
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 13 Issue 1

In this issue of the Scandinavian Journal of Pain, Lars Sturesson and his co-workers report on patients’ experiences with pain management in the emergency department of a general hospital in Stockholm, Sweden [1]. The authors found that after the intervention, requiring mandatory documentation of patients’ pain intensities, performed by registered nurses (RNs) in the emergency department (ED), there was increased administration of analgesics by RNs, but the intervention did not affect the patients’ satisfaction with their pain management. In this hospital the RNs in the ED are able to administer non-opioid and opioid analgesic drugs according to nurse- and physician-developed guidelines.

1 Why did increased use of analgesic drugs not improve the patients’ reported pain intensities and satisfaction with pain management?

This paradoxical finding calls for an explanation. A conventional explanation would be that the instruments used for measuring pain did not have the necessary sensitivity (resolution) and validity, thus not capturing the decrease in pain that the patients nevertheless must have experienced.

Pain-intensity measurement is important, but the problem probably has deeper roots than that. If we attempt to pragmatically break down the issue of pain reporting into its constituent parts, the following components may be identified: pain signal, pain perception, and pain rating. A further step could be the conversion, by the patient, of their pain rating into satisfaction with pain management.

Satisfaction with pain management would be affected by all the antecedent and contextual factors mentioned below.

The pain signal, loosely defined, consists of nociception or neuropathic pain processes in the somatosensory system. This pain signal can only be indirectly inferred in a clinical situation, and is therefore of limited interest in that context.

Pain perception, on the other hand, is poorly defined. In the framework of Cognitive Behaviour Theory (CBT), it would be construed as the patient’s thoughts, feelings, and actions in response to a pain signal. The determinants of these reactions in the patient are the antecedents and contextual cues that are the subject matter of CBT and Acceptance and Commitment Therapy (ACT).

The pain rating finally, being at the top of the chain of events, is subject to anything that can influence the different parts of the process from pain signal, via pain perception to pain rating. In a clinical setting the pain rating is practically also our only access to the whole phenomenon of the patient’s pain. Nonverbal pain behaviour can help us to evaluate the pain perceived by the patient, but such cues are of limited value in adult ED patients, and can also be misleading.

2 Signs and symptoms of pain

That physicians rely more on signs than symptoms has also been pointed out as a major problem in the under-treatment of pain in the ED [2]. It is conceivable and indeed often suspected, that the patients’ pain ratings are biased due for example to malingering. The pain ratings would thus not properly reflect pain perception. There are reasons to believe, however, that patient pain ratings often are an accurate reflection of activity in brain areas consistently correlated to pain perception [3]. Thus, provided the pain ratings we use are sufficiently robust, we can, in most cases, assume that they mirror the patient’s pain perception. We have known, however, at least since the time of Fordyce that the perception of pain is subject to respondent and operant conditioning [4].

3 Expectation strongly influences pain perception

In experimental studies on healthy volunteers, expectations have been shown to significantly impact pain perception [3]. Identical pain stimulation and remifentanil infusion lead to pain reports varying almost two-fold depending solely on the expectations of the subjects. ED patients also appear to have greater expectations of pain relief than patients with postoperative pain [5]. They expect both a faster as well as a greater degree of pain relief. It must also be pointed out that pain is the chief complaint of patients in the ED, and that it often is undertreated, meriting the term “oligoanalgesia” [6].

4 Chronic pain and opioid-use among patients in an emergency department

Lars Sturesson and co-workers conclude that further studies on patient experiences with pain management in the ED, “exploring additional factors”, are needed. Against the background presented above, I would argue that these additional factors are not completely unknown. I think it is safe to say that the factors involved are those that influence the perception of pain. Two such factors are the intensity as well as the type of pain involved. We do not know the percentage of the patients in the study in question that were suffering from chronic pain, or if they were on opioids. This is important, partly because the ability to rate experimental pain has been found to be high in healthy controls without pain, but poor in chronic pain and in healthy volunteers administered opioids [7].

5 Multiple factors, in addition to nociception, determine pain perception and pain behaviour

It has furthermore been proposed that measuring pain intensity in chronic pain patients is not only misguided, but also potentially harmful for the patient [8]. This view is difficult to accept for many pain clinicians, and has been challenged [9]. The message here I believe is not that the patients’ pain ratings are a biased reflection of their pain perception, but that their pain perceptions to a large extent reflect factors other than nociception. The interplay between these factors is probably orchestrated by the prefrontal cortex, the main player in pain processing in humans [10]. The diverse contextual inputs to the brain along with antecedent factors such as learning history determine behaviour.

Making sense of confusing facts such as the findings of Lars Sturesson and co-workers [1] as well as improving pain management in the ED arguably requires a better understanding of why we human beings behave the way we do. This understanding would include the physicians, as well. General practitioners’ beliefs about fear-avoidance can negatively influence their following of treatment guidelines [11]. I would therefore suggest that the future research called for above, should be based in contextual behavioural science [12].

Returning to the study in question [1], how can we interpret the results in the conceptual framework presented above? First, did the analgesics not significantly diminish the pain signal? If the initiating mechanisms of the patients’ pain were relatively resistant to conventional analgesics, that would be possible. Such would be the case if the pain were for example mainly neuropathic. I would say that the pain in unselected ED patients is not likely to be unresponsive to conventional anti-nociceptive analgesics. So, the pain signal was probably attenuated. Skipping to the final step, was the perception of pain reliably rated by the patients? In view of the evidence from imaging studies (see above) we can probably assume that on the group level there was no bias in the ratings, i.e. the pain ratings relatively accurately reflected the patients’ pain perception.

Summing up, we are left with the conclusion that even though the pain signal was diminished, the patients’ perception of pain was not markedly influenced by the increased use of analgesic drugs. Other factors, such as the patients’ expectations of degree and timing of pain relief, probably dominated. In this analysis, the paradox found by Lars Sturesson and co-workers has been narrowed down to the connection between the pain signal and the patient’s perception of pain. Exploring this connection requires a joint venture of pain clinicians and behavioural psychologists.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2016.06.006.

Pain Section, Department of Anaesthesia, Karolinska University Hospital, Huddinge,14186 Stockholm, Sweden. Tel.: +46858580000; fax: +46858586440.

  1. Conflict of interest: None declared.

References

[1] Sturesson L, Falk A-C, Castrén M, Niemi-Murola L, Lindström V. Mandatory documentation of pain in the emergency department increases analgesic administration but does not improve patients’ satisfaction of pain management. Scand J Pain 2016;13:32–5.Search in Google Scholar

[2] Carter D, Sendziuk P, Eliott JA, Braunack-Mayer A. Why is Pain still under-treated in the emergency department? Two new hypotheses. Bioethics 2016;30:195–202, http://dx.doi.org/10.1111/bioe.12170. Epub 2015 Jun 24.Search in Google Scholar

[3] Bingel U, Wanigasekera V, Wiech K, Ni Mhuircheartaigh R, Lee MC, Ploner M, Tracey I. The effect of treatment expectation on drug efficacy: imaging the analgesic benefit of the opioid remifentanil. Sci Transl Med 2011;3:70ra14, http://dx.doi.org/10.1126/scitranslmed.3001244,16.Search in Google Scholar

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Published Online: 2016-10-01
Published in Print: 2016-10-01

© 2016 Scandinavian Association for the Study of Pain

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  2. Scandinavian Journal of Pain
  3. Editorial comment
  4. Increased deep pain sensitivity in persistent musculoskeletal pain but not in other musculoskeletal pain states
  5. Clinical pain research
  6. Increased deep pain sensitivity in persistent musculoskeletal pain but not in other musculoskeletal pain states
  7. Editorial comment
  8. Patient Reported Outcomes (PROs) are sensitive outcome-variables in patients with chronic pain: Importance of self-efficacy
  9. Observational study
  10. Using patient reported outcomes in oncology clinical practice
  11. Editorial comment
  12. Cortical reorganization of the healthy hand in upper-limb complex regional pain syndrome(CRPS): Is reorganizations of common beliefs about CRPS necessary?
  13. Original experimental
  14. An exploration into the cortical reorganisation of the healthy hand inupper-limb complex regional pain syndrome
  15. Editorial comment
  16. Is there hope for the most complicated chronic pain patients facing back surgery?
  17. Educational case report
  18. A preoperative interdisciplinary biopsychosocial opioid reduction program in patients on chronic opioid analgesia prior to spine surgery: A preliminary report and case series
  19. Editorial comment
  20. Pain management in the Emergency Department – Still a long way to go?
  21. Clinical pain research
  22. Mandatory documentation of pain in the emergency department increases analgesic administration but does not improve patients’ satisfaction of pain management
  23. Editorial comment
  24. Pain relief during childbirth: Efficacy and safety of prolonging labour-analgesia with morphine directly into the lumbar cerebro-spinal-fluid (CSF)
  25. Systematic review
  26. Prolonging the duration of single-shot intrathecal labour analgesia with morphine: A systematic review
  27. Editorial comment
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  29. Systematic review
  30. A meta-analysis of fear-avoidance and pain intensity: The paradox of chronic pain
  31. Editorial comment
  32. Local infiltration analgesia(LIA), risk of local anaesthetic systemic toxicity (LAST) and kidney failure from NSAID in elderly patients
  33. Topical review
  34. Local infiltration analgesia in knee and hip arthroplasty efficacy and safety
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  39. Editorial comment
  40. The relationship between chronic pain and cardiovascular disease: Squaring the circle?
  41. Systematic review
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  43. Editorial comment
  44. Optimists fare better when chronic pain strikes – Or does pain related disability make us pessimists?
  45. Observational study
  46. Constructs of health belief and disabling distal upper limb pain
  47. Editorial comment
  48. Attitude and belief of pain-therapists are important when trying to help chronic pain patients: The Norwegian version of the Pain Attitudes and Beliefs Scale (PABS) improved by Rasch analysis
  49. Observational study
  50. Rasch analysis resulted in an improved Norwegian version of the Pain Attitudes and Beliefs Scale(PABS)
  51. Editorial comment
  52. Anxiety could play a larger role than depression in migraine headache
  53. Clinical pain research
  54. The relative importance of anxiety and depression in pain impact in individuals with migraine headaches
  55. Editorial comment
  56. Bringing the lab to the people: Experimental pain testing in the general population
  57. Clinical pain research
  58. Pressure and cold pain threshold reference values in a large, young adult, pain-free population
  59. Editorial comment
  60. Improving pain treatment in children
  61. Clinical pain research
  62. A randomized controlled trial of amitriptyline versus gabapentin for complex regional pain syndrome type I and neuropathic pain in children
  63. Editorial comment
  64. Gut gateway to generalized pain
  65. Original experimental
  66. A low fermentable oligo-di-mono saccharides and polyols(FODMAP) diet reduced pain and improve ddaily life in fibromyalgia patients
  67. Editorial comment
  68. Measuring outcomes of pain management
  69. Clinical pain research
  70. Osteoarthritis patients with pain improvement are highly likely to also have improved quality of life and functioning. A post hoc analysis of a clinical trial
  71. Clinical pain research
  72. Construct validity and reliability of Finnish version of Örebro Musculoskeletal Pain Screening Questionnaire
  73. Observational study
  74. Total sleep deprivation and pain perception during cold noxious stimuli in humans
  75. Corrigendum
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https://doi.org/10.1016/j.sjpain.2016.09.007

Articles in the same Issue

  2. Scandinavian Journal of Pain
  3. Editorial comment
  4. Increased deep pain sensitivity in persistent musculoskeletal pain but not in other musculoskeletal pain states
  5. Clinical pain research
  6. Increased deep pain sensitivity in persistent musculoskeletal pain but not in other musculoskeletal pain states
  7. Editorial comment
  8. Patient Reported Outcomes (PROs) are sensitive outcome-variables in patients with chronic pain: Importance of self-efficacy
  9. Observational study
  10. Using patient reported outcomes in oncology clinical practice
  11. Editorial comment
  12. Cortical reorganization of the healthy hand in upper-limb complex regional pain syndrome(CRPS): Is reorganizations of common beliefs about CRPS necessary?
  13. Original experimental
  14. An exploration into the cortical reorganisation of the healthy hand inupper-limb complex regional pain syndrome
  15. Editorial comment
  16. Is there hope for the most complicated chronic pain patients facing back surgery?
  17. Educational case report
  18. A preoperative interdisciplinary biopsychosocial opioid reduction program in patients on chronic opioid analgesia prior to spine surgery: A preliminary report and case series
  19. Editorial comment
  20. Pain management in the Emergency Department – Still a long way to go?
  21. Clinical pain research
  22. Mandatory documentation of pain in the emergency department increases analgesic administration but does not improve patients’ satisfaction of pain management
  23. Editorial comment
  24. Pain relief during childbirth: Efficacy and safety of prolonging labour-analgesia with morphine directly into the lumbar cerebro-spinal-fluid (CSF)
  25. Systematic review
  26. Prolonging the duration of single-shot intrathecal labour analgesia with morphine: A systematic review
  27. Editorial comment
  28. The intricate relationship amongst pain intensity, fear and avoidance
  29. Systematic review
  30. A meta-analysis of fear-avoidance and pain intensity: The paradox of chronic pain
  31. Editorial comment
  32. Local infiltration analgesia(LIA), risk of local anaesthetic systemic toxicity (LAST) and kidney failure from NSAID in elderly patients
  33. Topical review
  34. Local infiltration analgesia in knee and hip arthroplasty efficacy and safety
  35. Editorial comment
  36. Analysis of pain-intensity measurements
  37. Topical review
  38. How to analyze the Visual Analogue Scale: Myths, truths and clinical relevance
  39. Editorial comment
  40. The relationship between chronic pain and cardiovascular disease: Squaring the circle?
  41. Systematic review
  42. Assessing the relationship between chronic pain and cardiovasculardisease: A systematic review and meta-analysis
  43. Editorial comment
  44. Optimists fare better when chronic pain strikes – Or does pain related disability make us pessimists?
  45. Observational study
  46. Constructs of health belief and disabling distal upper limb pain
  47. Editorial comment
  48. Attitude and belief of pain-therapists are important when trying to help chronic pain patients: The Norwegian version of the Pain Attitudes and Beliefs Scale (PABS) improved by Rasch analysis
  49. Observational study
  50. Rasch analysis resulted in an improved Norwegian version of the Pain Attitudes and Beliefs Scale(PABS)
  51. Editorial comment
  52. Anxiety could play a larger role than depression in migraine headache
  53. Clinical pain research
  54. The relative importance of anxiety and depression in pain impact in individuals with migraine headaches
  55. Editorial comment
  56. Bringing the lab to the people: Experimental pain testing in the general population
  57. Clinical pain research
  58. Pressure and cold pain threshold reference values in a large, young adult, pain-free population
  59. Editorial comment
  60. Improving pain treatment in children
  61. Clinical pain research
  62. A randomized controlled trial of amitriptyline versus gabapentin for complex regional pain syndrome type I and neuropathic pain in children
  63. Editorial comment
  64. Gut gateway to generalized pain
  65. Original experimental
  66. A low fermentable oligo-di-mono saccharides and polyols(FODMAP) diet reduced pain and improve ddaily life in fibromyalgia patients
  67. Editorial comment
  68. Measuring outcomes of pain management
  69. Clinical pain research
  70. Osteoarthritis patients with pain improvement are highly likely to also have improved quality of life and functioning. A post hoc analysis of a clinical trial
  71. Clinical pain research
  72. Construct validity and reliability of Finnish version of Örebro Musculoskeletal Pain Screening Questionnaire
  73. Observational study
  74. Total sleep deprivation and pain perception during cold noxious stimuli in humans
  75. Corrigendum
  76. Corrigendum to ‘Reliability of pressure pain threshold testing in healthy pain free young adults’ [Scand. J. Pain 9 (2015) 38–41]
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