We Suck – 6 Tips for Controlling Pain in the Emergency Department

Bloody Pain Management!

I was thinking today we suck at pain management.  I can definitely manage this patient’s pain better.  So why don’t I?  Why do I struggle to manage my patient’s analgesia? Am I too busy? What’s the problem? Why does my medical student think giving pain relief is a bad idea?

  • If this is an issue where you work it seems you are not alone – it has been shown that we do frequently under treat pain and suffering
Vassiliadis (2002) – “The median time to analgesia was 2 h 48 min in patients with pelvic fractures”
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Not Convinced? – Studies Showing We Suck

Hip Fractures

  • Ambulance officers made a clinical diagnosis of fractured neck of femur in 68% of cases. In 49% of cases no analgesia was given. Patients were given a higher triage category and pain relief faster if they had been given analgesia by ambulance officers

  • Only a modest proportion of patients with fractured neck of femur received pre-hospital analgesia and delays to analgesia in the emergency department are considerable. Strategies to address the delivery of appropriate analgesia to this group of patients should be developed.”


  • “In pediatric and adult patients, pain medications were frequently not part of ED treatment for fractures, even for visits with documented moderate or severe pain. Pain severity scores were often not recorded.”
  • “Pediatric patients were least likely to receive analgesics, especially narcotics.”

  • “This study revealed a very high prevalence of pain among patients in the emergency department and showed that, overall, pain was poorly treated.”

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  • “Medical students in this survey showed the lowest regard for patients with unexplained abdominal pain, and these attitudes were worse in the most experienced medical students.”

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Simpson et al (Edinburgh Medical School – 1871)

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The Professor of Pain

Based on the above we reckon the fasted track to become a university professor through publication would be to show how bad we are at prescribing for pain.

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Need and Abuse

75% of patients in the ED have a painful condition and less than 3% are drug abusers.

Doctors and Nurses must make judgments every shift, on nearly every patient; pain management is but one such judgement.  Healthcare professionals should carefully consider their comfort levels with the balancing act between “losing” to drug seekers (<3%) and denying analgesia to patients who are genuinely in need (>68%).

So, why are we holding back pain relief? Do we not actually believe that are patient’s have pain?  Are we choosing to hurt the patient?  Is it possible that as educated (at least in our own mind) health professionals we have a cultural and moral biases towards patient’s in pain?


Bias as a Barrier

Our ingrained (often subconscious) bias re-enforces our inability and/or unwillingness to treat pain and suffering in the ED despite the fact we have effective treatments.

Amazingly, there is good evidence that medical students become less sympathetic towards suffering patients through their training by exposure to the behaviour of more senior doctors.

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6 Tips to Improve on your Next Shift

  • (1) The most common issue with pain management in the Emergency Department is the under treatment of pain.
    • This is known as “oligoanalgesia
    • Be prepared to diagnose and treat oligoanalgesia when you see it.
  • (2) Most healthcare providers “do not titrate opioids to what the patient wishes; rather, they titrate – if they titrate at all to either a pain score that in their minds is ‘low enough’ or to a set amount of medication they feel is safe or sufficient“.  
    • To optimise pain control communicate your ‘end points’ and titrate the medications. 
    • Accurate assessment and documentation of initial pain rating is important.
  • (3) On your next shift ask your patient: “Sir, would you like more pain medicine?”

Evaluation of this pain should be with use of objective pain scales completed by the patient, not relying on physician impression.

  • (5) In the context of acute pain there is minimal evidence that patients will get addicted to opioid analgesics…
  • (6) Select the most suitable analgesics at the right dose, frequency and administration route.  Certain analgesics are known to be ineffective – follow the best evidence from studies and local experts
    • Not all patients metabolise codeine to morphine so it may not be effective in up to 10% of patients
    • Patients on high doses of regular opioids (e.g. patients with malignancy) with ‘breakthrough’ pain should be given doses opioid analgesia at 1/6 of their total daily dose
    • Generally avoid Tramadol


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Recommended Reference

Book Recomendation

7 thoughts on “We Suck – 6 Tips for Controlling Pain in the Emergency Department

      1. pardon my inexperience. We try not to give it to the elderly patients but is it really that bad/clinically significant?

        Do you have a reference?

  1. Hi @MedSchoolNeverEnds

    – Re: Tramadol – I think it’s ok to give the medication as an alternative therapy (on the wards for refractory pain, neuropathic pain etc.).

    I have seen it (seem to) work quite well when I did anaesthetics and worked as part of the Acute Pain team. This makes sense because the mechanism of action is blocking noradrenaline and serotonin reuptake. It’s action is similar to tricyclic antidepressants. There is potentiation of descending neural pathways which in turn block nociceptive stimuli.

    My Contention is that it should not be used first line or alone and that care must be taken with it’s use to avoid the risk associated with overdose and drug interactions (serotonin syndrome).

    Weighing the Pros and Cons:

    Pros of Tramadol:
    1) Cost
    – not a lot
    2) Some evidence for Acute Pain (long term use in Europe)
    3) Less Dependence compared with Oxycodone
    – Reference – http://www.acepnow.com/article/non-opioid-pain-medications-consider-emergency-department-patients/3/
    4) Can be used in Neuropathic pain
    – Reference – http://www.ncbi.nlm.nih.gov/pubmed/15106216

    Cons of Tramadol
    1) Serotonin Syndrome
    – Common
    2) May be ineffective
    3) Refractory Seizures in Overdose
    4) Side Effects without analgesia
    – Anecdotal
    5) Abuse – commonly seen in Middle Eastern Countries
    – Reference – http://electronicintifada.net/content/drug-addiction-rise-besieged-gaza/8323

    Thanks for the Feedback


  2. Also the point of the post is NOT to bag out Tramadol. It’s to get people thinking about how we can improve pain relief in the first few hours of the patient’s arrival in hospital…

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