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Opportunities
and Research Horizons in Pain Management
Introduction
Pain Management Horizons
The barriers to adequate
care of emergency department patients in pain are numerous. 1 While
some find fault with emergency medicine in this area, our specialty
is certainly not alone in undertreating pain. Studies have documented
oligoanalgesia, the undertreatment of pain, in a variety of patient
groups, including medical and surgical inpatients, nursing home residents,
cancer patients, and others. 2,3,4 These barriers are common to all
medical specialties (inadequate education, lack of institutional commitment)
but many are more salient to the emergency medicine community (time
demands, lack of patient-physician continuity, diagnostic uncertainty).
5
Deficiencies in pain treatment
have prompted a number of initiatives to improve the quality of pain
management, including practice guidelines from what is now the Agency
for Healthcare Research and Quality, quality improvements guidelines
from the American Pain Society, and beginning in 2001, revised pain
standards from the Join Commission on Accreditation of Healthcare
Organizations. 6,7,8
Despite the pessimism that
colors this discussion, it is apparent that analgesic practices are
evolving rapidly. The latest emergency department data from the National
Hospital Ambulatory Medical Care Survey reveals that from 1997 through
2001, there has been an impressive 18% increase in analgesic use in
U. S. emergency departments (from 47.2 to 56.2 mentions per 100 visits)
with marked increases in both nonsteroidal anti-inflammatory agents
and opioid analgesics. 9
We do not know the reasons
for this increase; however, a number of factors may be at work. These
influences include policy and regulatory initiatives, institutional
quality improvement programs, pharmaceutical marketing campaigns,
educational efforts, and new knowledge from basic and clinical research,
among others. This topography of influence is important to understand
if we are to move from passive observers, to active instigators of
change.
With regard to policy,
this is an active time in the area of pain management. In 2001, the
U. S. Congress declared this the "Decade of Pain Control and
Research" and the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) issued revised standards mandating pain assessment
in our emergency departments. More recently, Congressman Mike Rogers
(R-MI) introduced The National Pain Care Policy Act of 2003 (H.R.
1863), another step in the federal recognition of pain as an important
health care issue. This bill would create a National Center for Pain
and Palliative Care Research at the National Institutes of Health
and provide additional funds for pain research and education. In addition,
it would create a White House Conference on Pain Care to identify
key barriers to high quality pain management practices and establish
a clearinghouse at the Agency for Healthcare Research and Quality
to collect and disseminate protocols and evidence-based practices
regarding pain and to clinicians and the general public.
The impact of these policy
and regulatory initiatives is difficult to quantify. The revised JCAHO
standards have generated some grumblings from emergency physicians
about imposed regulations and in preliminary data from our research
efforts, they seem to have prompted increased documentation of pain
intensity, although perhaps little else. This documentation reveals
that, in general, our patients present with extremely high levels
of pain. In one published study, fully half of all patients presenting
to the emergency department with pain experienced pain of severe intensity
(8 to 10 on a ten-point numerical rating scale) with median overall
scores of eight. 10
Despite the intention to
promote pain intensity as an outcome measure with which to judge the
quality of our efforts, our ongoing research finds that pain intensity
is measured only once in most departments, at the time of patient
arrival, without additional measures that might reflect the impact
of our therapies. This documentation results largely from changes
in medical record formats and perhaps mirrors medicine's traditional
view of pain as a diagnostic indicator rather than an outcome deserving
of attention in its own right.
Whether JCAHO standards
have yet had an impact on practice is an unanswered question. Nonetheless,
any documentation of pain experience is a necessary step in the right
direction. The JCAHO initiative is not static, and we look forward
to the forthcoming pain management performance measures and standards
resulting from these efforts. 11 Thus far, our specialty has been
less engaged in the development of pain policy. Although ACEP has
specific clinical policies addressing abdominal and chest pain as
well as the Clinical Policy for Procedural Sedation and Analgesia
in the Emergency Department, these policies do not address the general
treatment of pain. Currently, a subcommittee of the Clinical Policies
Committee is at work on such a policy statement and we look forward
to its completion and dissemination.
Pharmaceutical marketing
has a remarkable power to influence our practice. Over the past few
years, many pages of the Annals advertising section have touted the
supposed benefits of cyclooxygenase-2 selective inhibitors, despite
the lack of evidence for their superiority in our patient population
over nonselective (and cheaper) nonsteroidal anti-inflammatory drugs.
We will continue to be the targets of pharmaceutical houses offering
new analgesic agents and delivery systems that may (or may not) represent
valuable additions to our analgesic armamentarium.
In fact, it is rare that
analgesic research leading to U. S. Food and Drug Administration (FDA)
approval involves the emergency department, thus approved analgesics
are tested in patients who may or may not resemble those we treat.
To develop analgesics that are effective for emergency department
patients, we must take on the task of promoting research in the emergency
department setting. Results of clinical trials conducted in our departments
can then be translated into clinical practice with added confidence.
The lack of emergency medicine
involvement in the FDA's analgesic regulatory process may have had
additional negative consequences. An FDA Advisory Committee addressing
the issue of QT prolongation associated with droperidol did not include
a representative from our specialty, despite the popularity of this
drug among emergency physicians. 12 Likewise, recurrent shortages
of drugs, particularly prochlorperazine, fentanyl, naloxone, have
at times adversely affected our analgesic practices. Although these
shortages are of unclear and complex provenance, our active, ongoing
engagement in the Drug Shortage Program of the FDA's Center for Drug
Evaluation and Research will, in the long run, best serve our patients
and our colleagues. 13
Regarding education, Drs.
Rupp and Delaney note that The Model of the Clinical Practice of Emergency
Medicine does not include a formal pain management curriculum. Most
medical schools and emergency medicine residencies offer little in
the way of pain didactics. Combating this trend through curriculum
reform within medical schools and residencies will require time and
the development of leadership within our academic training institutions.
Given the role that teachers
of emergency medicine have increasingly assumed in the early medical
school curriculum, we have a tremendous opportunity to shape the attitudes
of all future physicians regarding pain treatment, not just those
who choose to train in emergency medicine. Given our strategic location
in the front lines of patient care, and the relative youth of our
specialty, we may have particularly pertinent lessons to transmit
to medical students regarding pain management practices, with less
dogma to obscure a critical examination of current pain management
practice.
Support for this optimism
can be seen in emergency medicine's critical examination of the surgical
dictum regarding withholding of opioid from patients with acute abdominal
pain. One doubts that in its 20th edition, Cope's Early Diagnosis
of the Acute Abdomen would have undergone the revisions discussed
by Drs. Rupp and Delaney were it not for the research conducted by
these investigators. One of emergency medicine's strengths is that
it has yet to ossify into a traditional specialty, with rigid, dogmatic
conceptions of appropriate pain management practice.
Much of our progress in
emergency medicine pain research stems from formative work begun ten
years ago by Drs. Jim Ducharme and William H. Cordell. In 1994, with
support from the Canadian Association of Emergency Physicians and
the Quebec Association of Emergency Physicians, they convened the
First International Symposium on Pain Research in Emergency Medicine
in Montreal. This symposium brought together a number of pain researchers
in the U.S. and Canada who subsequently authored 23 articles in the
April 1996 issue of the Annals of Emergency Medicine addressing pain
research standards. 14
More recently, The Mayday
Fund, a New York City-based private foundation, funded grants to the
Emergency Medicine Foundation and the American Society for Law, Medicine
and Ethics to help increase our knowledge base and create a forum
where medical, legal, and ethical issues related to pain and emergency
medicine may be discussed. 15 In addition, for two years, the American
Pain Society has sponsored scholarships for emergency physicians to
increase our interactions with the broader pain community. These initiatives
have provided opportunities and guidance for a growing network of
emergency medicine pain researchers.
Unfortunately, at the federal
level, funding for pain research has lagged behind policy developments.
Although pain costs the U. S. $79 billion annually in lost productivity,
results in more than 20% of visits to all physicians and 70% of visits
to emergency departments, only 0.6% of the current National Institutes
of Health (NIH) budget is devoted to basic and clinical pain research.
16,17,18,19
While many factors contribute
to the changing of clinical practice, physician leadership has been
identified as a dominant component of successful reform efforts. 20
Although Donald Berwick once characterized clinical health care leaders
as, " …trained to ride out the storm, not to create one,"
I believe that our specialty is fundamentally different in this respect.
21
Emergency medicine was
created in response to the public's demand for high quality urgent
and emergent medical care. Although much remains to be learned in
the areas of pain education, research, and policy, strong emergency
physician leadership can immediately begin to close the gap between
what we know about high quality pain management and what we actually
do.
There is a great power
in the naming of things. Going forward, we should begin by defining
our own standards for excellence in pain practice and promote quality
improvement initiatives to achieve these goals. The purpose of this
editorial is to help us understand important factors that shape our
pain practices. We have explored what we know about this topography
of influence but the most satisfactory method of understanding regions
yet to be charted is to create them ourselves. Although we will find
many allies in our efforts to ameliorate pain and suffering, the duty
to provide superior emergency department pain management remains our
own.