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Study says chronic pain is poorly managed in ED
Care is 'very different from acute pain'
When 103 ED patients, 34 ED physicians, and 44 ED nurses were surveyed, they all agreed on one thing: Treating chronic pain in the ED is a "low priority."1
"It was not surprising to learn that the ED practitioners surveyed attached a low priority to chronic pain," says Barth Wilsey, MD, the study's lead author and associate clinical professor of anesthesiology and pain medicine at the Pain Academic Office of the University of California — Davis Medical Center in Sacramento. "However, it was surprising to learn that providers thought the potential for addiction, dependence, diversion, and forged prescriptions was low in the ED, given the findings in another one of our studies where we learned that patients who came to the ED seeking pain medications had a high propensity for prescription opioid abuse," he says.2
This study, published in the same issue of Pain Medicine, revealed that 81% of ED patients showed a propensity for prescription opioid abuse, as determined by their scores on the Screener and Opioid Assessment for Patients with Pain (SOAPP). (Editor's note: This tool, along with background information and scoring instructions, can be obtained at no charge at www.painedu.org/soap.asp.)
However, Wilsey says as pain neither can be verified nor disproved in the brief time interval allotted to the ED visit, you should err on the side of the patient. "Provide a small allotment of opioid medications that will last until the patient can be seen by a continuity provider," he recommends.
Managing chronic vs. acute pain
Chronic pain is difficult to manage in the ED, says Vicki A. Alverson, RN, BSN, a clinical nurse specialist at the Emergency Care Center at Covenant Healthcare in Saginaw, MI. "It is very different from acute pain," she says.
With acute pain, there is often an obvious source or injury causing the discomfort, but with chronic pain, it might be difficult for nurses and physicians to evaluate the exact cause or source for the pain, says Alverson. "Chronic pain individuals can also present with behaviors and personalities that make it difficult to manage their care," she says. "But all patients should be treated with compassion and respect. We must provide comfort measures to all individuals that seek our care."
Assessing the physiological indicators of pain — elevated heart rate, elevated blood pressure, and increased work of breathing — is important, but don't forget to stop and look at your patient, says Alverson. "Is this patient crying or diaphoretic? What is the position of their body?" she asks.
Alverson says like many ED nurses, she treats a significant population of low-income individuals with limited resources. "Ask these patients whether they have sufficient heat, as cold weather can precipitate many chronic conditions, and whether they have the finances available to get medications," she advises.
Identify any environmental or psychological issues that might be increasing or precipitating the pain, such as stress, fear, or lack of knowledge. "Helping to reduce or eliminate these factors may help to provide comfort for chronic pain patients," says Alverson. For example, at Covenant Healthcare's ED, patient advocates assist patients with getting prescriptions and make arrangements with local homeless shelters if needed.
Many times, if you can reduce a patient's anxiety, it will help to reduce their pain level as well, says Alverson. "Educational and teaching can be a beneficial intervention to reducing a patient's anxiety," she says. "Explaining all tests and procedures, answering questions, and active listening are important."
Take holistic approach with chronic pain cases
A woman reports an increase in pain all over, increase in fatigue, and increase in dyspnea. What do you do for this patient?
"Her most pressing complaint was the pain," reports Vicki A. Alverson, RN, BSN, a clinical nurse specialist at the Emergency Care Center at Covenant Healthcare in Saginaw, MI. "She told me it had been getting worse over the last four days, and 'I can no longer stand it.'"
The woman went on to state that she thought her fatigue and shortness of breath was due to the fact that she starting smoking again to help her deal with the pain at home. Alverson also learned that her patient was distressed because the pain made her unable to attend church. She had just completed a round of chemotherapy for lung cancer, and her pain medications weren't relieving her pain. She also perceived a lack of support from her family.
When treating this patient, Alverson took all these physiologic, cognitive, and situational factors into account. "We provided Mrs. Jones with intravenous pain medications. When she was discharged, we changed her to oral pain medication to help her until her follow-up appointment with her primary physician," she says. "We also did intravenous hydration and performed diagnostic lab tests to determine if there was any other physiologic factor that could be affecting the pain."
Alverson reinforced the need for the patient to stop smoking, and she encouraged her to find other support systems such as friends from her church group or a close neighbor. "We also discussed eating nutritious foods and keeping well-hydrated to help reduce fatigue," she said.