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INTRODUCTION

Pain is the most common presenting symptom for patients coming to the ED, with 70% to 80% of all patients having pain as their primary complaint.1,2 Despite increasing research and information about pain management, oligoanalgesia, or the undertreatment of pain, persists.3 While all patients are susceptible to oligoanalgesia, certain subgroups, such as ethnic minorities, the aged, the very young, and those with diminished cognitive function, are more at risk (Table 35-1).4-7 Pain management can also be negatively influenced by concerns of prescription opioid misuse, a situation declared to be a public health epidemic in North America.8 An initial prescription of opioids, such as upon ED discharge, has been associated with persistence of opioid use months after the original visit.9 Nevertheless, appropriate treatment of acute severe pain should not be withheld for fear of facilitating drug misuse; rather, opioid use should be but one of many options considered in pain management.10 Pain and addiction are not mutually exclusive.

TABLE 35-1Barriers to Adequate ED Pain Control

Specific measures to treat pain should occur in addition to, and at the same time as, treatment of the underlying illness or injury. It is not possible to generalize the extent and quality of pain control needed for a specific patient. For example, pain is an indicator of ongoing cardiac ischemia, and the goal should be to eliminate all pain. On the other hand, a patient with a traumatic injury may choose to endure more pain out of personal or cultural beliefs. Whenever possible, medications that act on specific sites that initiate the pain signal—a mechanistic approach—are preferred to agents such as opioids that mask pain, which is more a symptomatic approach. Current migraine treatment is an excellent example of the mechanistic approach; preferred treatment includes a serotonin agonist (triptan) or a dopamine antagonist (phenothiazine or metoclopramide), rather than opiates.11

PATHOPHYSIOLOGY

Pain is the physiologic response to a noxious stimulus, whereas suffering—the expression of pain—is modified by the complex interaction of cognitive, behavioral, and sociocultural dimensions. Individual pain experience is therefore not static, but varies depending on current and past medical history, physical and emotional maturity, cognitive state, meaning of pain, family attitudes, culture, and environment. Emotions can modify pain either negatively or positively: fear and anxiety may accentuate pain, ...

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