Cameron: Is Analgesia Helping or Hurting?

Pain is the most common reason for people to attend an emergency department (ED). Pain reported in an emergency can result from direct physical injury, ischemia, and inflammation, and the degree of reported pain is influenced by many factors such as severity of illness, patient attitudes, chronicity of pain, environment, and previous experience.
Over the last two decades there has been a particular focus on ensuring that emergency patients receive rapid and effective analgesia,1,2 along with an emphasis on accurate documentation of patient-reported pain and the response to interventions to relieve pain. Quality improvement programs have been developed to ensure that EDs have effective pain mitigation processes.3 This has all resulted in a much greater degree of analgesic use in EDs, and much greater use of narcotics, which, for many clinicians, represent the “ultimate” analgesic.

In parallel, we have seen explosive growth in the use of prescription analgesics in the general population, including narcotics. So much so that the American Society of Addiction Medicine put out an “Opioid Addiction 2016 Facts and Figures” bulletin stating:
“… Of the 21.5 million Americans 12 or older that had a substance use disorder in 2014, 1.9 million had a substance use disorder involving prescription pain relievers and 586,000 had a substance use disorder involving heroin…
“…Drug overdose is the leading cause of accidental death in the US, with 47,055 lethal drug overdoses in 2014. Opioid addiction is driving this epidemic, with 18,893 overdose deaths related to prescription pain relievers, and 10,574 overdose deaths related to heroin in 2014….”

Similar figures have been published in Australia and other developed countries as we grapple with a problem that appears to kill more people than car crashes.

As an emergency doctor, I have generally felt that the prescription narcotic epidemic is something I have little control over. I see evidence of narcotic abuse when patients come to the ED with overdose, and when malingerers ask me to prescribe narcotic analgesia. Somehow, I have never felt that I am personally a cause of the problem.

Recently, however, some commentators have begun questioning our role as acute physicians in propagating the narcotic epidemic,4 and there is evidence that we may actually precipitate addiction in some patients.5 Clearly we are not responsible for all societal ills, and many patients with psychosocial problems will experience some form of addiction or substance abuse. We do, however, initiate a lot of analgesia and set the analgesic program for many patients. The starting point for many patients on their journey to prescription drug dependency may very well be our initial prescription, which is then continued into the community.

In the ED there are many “minor conditions” such as back pain, renal colic, or a sports injury where patients are frequently prescribed narcotic analgesics to “effectively and rapidly” reduce pain. Nurses are instructed to inquire about pain using a numerical rating score, and patients will respond with a number to report severity. The score given is impossible to validate because it is obviously a subjective number—only the patient can rate pain. Importantly, there are secondary gains that may cause the patient change their score, such as reducing their waiting time, getting more attention, and so forth.

At a practical level, the value of the pain score is open to question. All of us have seen a patient sleeping, only to have the nurse report that pain is 10/10. I am not sure what this means.
A significant driver toward using “stronger” analgesics is that the nurse is mandated to respond in many EDs to control the pain quickly. This is to meet key “pain metrics” and thus show that the ED is a high performing unit.

This whole dynamic has created an interesting approach, such that most EDs now have nurse initiated analgesia, including narcotics.6 It has also created a shorthand style, where the nurse will say, “Pain score is 9/10, can I give oxycodone?” The doctor, in the middle of ten tasks, will reply to give oxycodone, with the intent to review later. In the case of physical injury, reassurance, splinting, elevation, compression, ice, local anesthetic, and many other interventions, may have been more effective. However, given the time imperative and the “quality metric,” all these options would have delayed time to analgesia and affected “quality ratings” for the ED. The irony of the situation is obvious to most EPs.

In addition to the time imperative, there are other issues at play. Narcotics are not the most effective analgesic for many emergency conditions. For example, our recent Lancet article on renal colic showed that IM NSAIDs were more effective than IV morphine and had fewer side effects.7 Yet many doctors and nurses persist in the belief that morphine is “stronger.” Paracetamol is as effective for many types of pain, but is often overlooked. Steroids are particularly effective in inflammatory conditions such as gout and tonsillitis and should be considered first line.

For chronic pain, which is a frequent reason for ED presentation, narcotics are commonly prescribed. Yet outside of patients suffering from terminal cancer, the evidence for use is very thin. In fact, there is increasing concern regarding the phenomenon of opioid induced hyperalgesia. This may occur acutely, but is most common in chronic exposure.8 The management of this condition is particularly problematic and is definitely not an ED program.
So what should we do about all this? Some EDs, such as St. Joseph’s ED in the USA, are looking at banning the use of opioid analgesia as first line treatment for pain. This may be extreme, but at least it would focus the mind of the clinicians on alternatives and possible consequences of poor analgesic use.

Personally, I would change the emphasis in analgesic metrics from pain scores and time to early and effective treatment of the condition. Giving a patient with a strained ankle oxycodone within five minutes of arrival is not the same level of quality care as assessing the patient quickly, elevating the leg, applying ice and compression, and discharging the patient. We should not be forced to give a tablet just because it makes the patient feel reassured and comfortable!

Patients presenting to the ED with pain need to be assessed quickly, but giving urgent narcotics is rarely first line management. Let’s help our patients and not kill them.

References

1. Wilson JE, Pendleton JM. Oligoanalgesia in the emergency department. Am J Emerg Med. 1989;7:620-623.
2. Motov SM, Khan AN. Problems and barriers of pain management in the emergency department: Are we ever going to get better? J Pain Res. 2009;2:5-11.
3. Management Standards. 2000. Cited on Jul 20, 2001. Available from http://www.jcaho.org/standard/pmhap.html. Joint Commission on the Accreditation of Healthcare Organizations. CAMH Revised Pain
4. Yealy DM, Green SM. Opioids and the emergency physician: ducking between pendulum swings. Ann Emerg Med. 2016. 2016 Aug;68:209-12.
5. Hoppe A, Kim H, Heard K. Association of emergency department opioid initiation. with recurrent opioid use. Ann Emerg Med. 2015 May;65:493-499.e4.
6. Kelly AM, Brumby C, Barnes C. Nurse-initiated, titrated intravenous opioid analgesia reduces time to analgesia for selected painful conditions. CJEM. 2005;7:149-154.
7. Pathan SA, Mitra B, Straney LD, et al. Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multigroup, randomised controlled trial. The Lancet. 2016 May 14;387(10032):1999-2007.
8. Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid-induced hyperalgesia. Pain Physician. 2011 Mar-Apr;14:145-61