1. Pain Management in the Emergency Department Leslie S. Zun, MD, MBA, FAAEM Chairman and Professor Department of Emergency Medicine Chicago Medical School and Mount Sinai Hospital Chicago, Illinois

2. Leslie Zun, MD, FAAEM Key Clinical Questions 1)How to assess a patient’s level of pain? 2)What adjuncts can be used for which type of pain? 3)What patient education can be useful when discharging this patient?

3. Leslie Zun, MD, FAAEM Key Learning Points 1)Determining the patient’s level of pain using an appropriate assessment tool improves the provision of care. 2)Adjuncts are useful additions to usual medication therapy. 3)Pain education at discharge from the emergency department is an essential component to good medical care.

4. Leslie Zun, MD, FAAEM Case 1: ED Visit 49 year old male presents to the ED with excruciating back pain after lifting a heavy ramp at work yesterday. Patient rates his pain a ten out of ten. Patient has had two prior episodes of back pain. The pain is in his buttock and right thigh. Patient has a history of non-insulin dependent diabetes. The patient’s past medical history demonstrated an otherwise healthy individual.

5. Leslie Zun, MD, FAAEM Case 1: ED Visit The PE revealed a lying uncomfortable in pain requesting pain medication. His vital signs were BP of 162/99, pulse of 73, respiratory rate of 19, afebrile. His heart, lungs and abdominal exam was normal. He had right sided back pain with radiation down his leg. Reflects were plus 2 in both legs and strength was 5 of 5 in each leg. Straight leg raises was decreased on the right side and sensation was normal.

6. Leslie Zun, MD, FAAEM Pain Assessment Why Aggressively Treat Pain? Good medical care Improved compliance in treatment plan Excellent customer service Pain relief met (satisfaction score 83 mm) and pain relief not met (satisfaction score 51 mm) Fosnocht DE, Swanson, ER, Bossart, P: Patient expectations for pain medication delivery. Am J Emerg Med. 2001;19:399-402. Prevent the progression from acute pain to chronic pain

7. Leslie Zun, MD, FAAEM Hangover Intensity Scale 1 Star Hangover - No pain No real feeling of illness 2 Star Hangover - No pain Something is definitely amiss 3 Star Hangover - Slight headache Stomach feels crappy 4 Star Hangover - Life sucks 5 Star Hangover - Dante's 4th Circle of Hell

8. Leslie Zun, MD, FAAEM Pain Assessment Behavioral approaches Observational techniques and scales Vocalization, facial expression and body movements Physiologic approaches Heart rate, blood pressure, sweating, stress hormones, transcutaneous oxygen, cortical evoked potential Subjective approach Self-reported Numerical, visual and categorical

9. Leslie Zun, MD, FAAEM Pain Scales in Adults Numerical rating scale measures pain from 0–10 or 0–100 with endpoints of “no pain” and “worst pain ever” Visual analog scale measures pain with a 10cm line with endpoints for “no pain and worst pain ever” Categorical pain scale for pain relief or pain intensity using a 4-point scale (no pain to severe pain)

10. Leslie Zun, MD, FAAEM Visual Analog Scale Ratio scale properties Ease and brevity of administration Minimal intrusiveness Conceptual simplicity Horizontal is superior to others Conventional 10 cm line Little to gain by adding dividing marks Neither numbers or verbal labels recommended Huskisson EC, Sturrock RD, Tugwell P. Measurement of patient outcome. Br J Rheumatol 1983;22:86-9. Price DD, McGrath PA, Rafii A, Buckingham B. The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain 1983;17:45-56.

11. Leslie Zun, MD, FAAEM Pain Scales in Adults Additional Assessments More extensive scales McGill Pain Questionnaire Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain 1975;1:277-99. Short Form McGill Questionnaire Melzack, R: The short-form McGill pain questionnaire. Pain 1987; 30:347-351. Pain and lifestyle Short Form 20 Health Survey Stewart, AL, Hays, RD, Ware. JE: The MOS short-form general health survey: reliability and validity in a patient population. Med Care 1988; 26:724-735.

12. Leslie Zun, MD, FAAEM Pain Assessment Special Populations Illiterate patients Cognitively impaired Pediatric patients

13. Leslie Zun, MD, FAAEM Illiterate and Cognitively Impaired Persons Numerical rating scales were found to have a higher reliability in patients who were illiterate than other pain scales Ferrraz, MB, Quaresmma, MR, et al: reliability of pain scales in the assessment of literate and illiterate patients with rheumatoid arthritis. J Rheum 1990;17:1022-1024. Pain Intensity Scale Krulewitch H, London MR, Skakel VJ, Lundstedt GJ, Thomason H, Brummel-Smith K. Assessment of pain in cognitively impaired older adults: a comparison of pain assessment tools and their use by nonprofessional caregivers. J Am Geriatr Soc 2000;48:1607-11. Hospice Approach Discomfort Scale Hurley AC, Volicer BJ, Hanrahan PA, Houde S, Volicer L. Assessment of discomfort in advanced Alzheimer patients. Res Nurse Health 1992;15:369-77.

14. Leslie Zun, MD, FAAEM Pediatric Pain Assessment Self-ReportBehavioralPhysiologic InfantsCry, cry time, movement facial exp., visual track HR BP RR Diaphoresis PreschoolFaces, ladder, Ocher, poker chip, color scale CHEOPS, Procedure behavioral rating scale School age/adol escents Visual, numerical, categorical Objective pain scale, others Beyer, JE, Wells, N: The assessment of pain in children. Ped Clinic NA 1989;36:837-853.

15. Leslie Zun, MD, FAAEM Pediatric Pain Scales Infants Observation of cry, bodily movement, facial expression and heart rate Preschoolers Face test Poker chips School aged children Visual analogue scales with happy and sad faces Adolescents Numerical and visual analog scales

16. Leslie Zun, MD, FAAEM Neonatal Facial Coding System Preterm, full-term, neonates and infants Facial muscle group movement Brow bulge Eye squeeze Naso-labial furrow Open lips Stretch mouth Lip purse Taut tongue Chin quiver Procedural pain Grunau, RVE, Craig, KD: Pain expression in neonates: Facial action and cry. Pain 1987; 28:395.

17. Leslie Zun, MD, FAAEM Preschoolers Facial Expression 3-12 years old Facial expressions to determine pain Three ethnic versions Beyer JE, Wells N: The assessment of pain in children Pediatr Clin North Am. 1989;36:837-52.

18. Leslie Zun, MD, FAAEM Poker Chip Tool Allows child to quantify pain Rationale is that young children do not know the meaning of pain but can understand the word “hurt” Validity and reliability established Procedure Ask children “Did it hurt?’ If the answer is “yes,” give them 4 poker chips 1 poker chip is for “a little hurt” and 4 poker chips are for “the most hurt you could ever have” Hester, NO: The pre-operative child’s reaction to immunization. Nurse Res. 1979;28:250-4.

19. Leslie Zun, MD, FAAEM Adjuncts Procedural analgesia Departmental analgesia Discharge analgesia

20. Leslie Zun, MD, FAAEM Painful Procedures Most painful procedures Nasogastric tube I & D Abscess Fracture reduction Urethral cauterization Use of local anesthetics was low Practitioners and individual patients pain ratings on procedures were poorly correlated Singer, AJ, Richman, PB, Kowalska, A, Thode, HC: Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures. Ann Emerg Med 1999; 33:652-658.

21. Leslie Zun, MD, FAAEM World Health Organization Pain Ladder http://www.who.int/cancer/palliative/painladder/en/

22. Leslie Zun, MD, FAAEM Adjuncts Medications Local and topical anesthetics Regional anesthesia Conscious sedation Choral hydrate Methohexital Pentobarbital Benzodiazepines Sedative analgesic agents Fentanyl Ketamine Nitrous oxide

23. Leslie Zun, MD, FAAEM Adjuncts Medications Benzodiazepine Used in anxiety, muscle injury, spasm and lancinating pain due to nerve injury Significant adverse effects Anticonvulsants Carbamazapine, gabapentin and phenytoin effective in chronic pain

24. Leslie Zun, MD, FAAEM Adjuncts Medications Caffeine Dose of 65-200mg are effective in combination with APAP, ASA, NSAIDS in headache, oral surgery and postpartum pain Hydoxyzine Shown to potentiate opioids Anti-emetic effect

25. Leslie Zun, MD, FAAEM Adjuncts Medications Corticosteriods Assistance in bone, visceral and neuropathic pain Antidepressants Amitriptyline useful in neuropathic pain such as post herpetic neuralgia and diabetic neuropathy SSRIs have not been well studied in pain

26. Leslie Zun, MD, FAAEM Adjuncts Medications Neurolyptics Benefit not shown Muscle relaxants Some effectiveness noted Adverse effects limit usefulness Ergotamines Use limited to migraine and cluster headaches

27. Leslie Zun, MD, FAAEM Adjuncts Medications 5-HT1 Receptor antagonists Use limited to migraine and cluster headaches Colchicine May have an additive benefit in OA patients Use in the treatment of gout

28. Leslie Zun, MD, FAAEM Adjuncts Standard Therapy Elevation Immobilization Ice Ice was found to be effective in reducing pain in patients who received ice prior to IV insertion Richman, PB, Singer, AJ, Flanagan, M, Thode, HC: The effectiveness of ice as a topical anesthetic for the insertion of intravenous catheters. Am J Emerge Med 1999;17:255-257. Meta analysis determined that ice may be useful for a variety of acute musculoskeletal pain Ernest, E, Fialka, V: Ice freezes pain? A review of the clinical effectiveness of analgesic cold therapy. J Pain symptom Manage 1994;9:56-59.

29. Leslie Zun, MD, FAAEM Adjuncts Psychological Preparation Strive to establish a trusting physician patient relationship Recognize the patients concerns and fears Explaining the steps of the procedure Accurate information of the procedure Realistic expectations of the procedure

30. Leslie Zun, MD, FAAEM Adjuncts Acupuncture Acupuncture has been reported as a good alternative to narcotics for the treatment of renal colic Lee, YH, Lee WC, Chen, MT et al: Acupuncture in the treatment of renal colic. J Urology 1992: 147:16-18. Reports of effectiveness in headache and back pain well studied Limited, if any, studies in the acute care setting

31. Leslie Zun, MD, FAAEM Adjuncts TENS Units TENS unit reduced pain in patients with acute rib fractures Sloan, JP, Muwanga, CL, Waters, EA, et al: Multiple rib fractures: transcutaneous nerve stimulation versus conventional analgesia. J Trauma 1986;26:1120-1123. The use of TENS units reduced children’s pain and the need for intervention for procedural pain Lander, J, Fowler-Kerry, S: TENS procedural pain. Pain 1993;52:209-216. TENS is thought to reduce pain in 70-80% of patients in 20 minutes to several hours Wall, PH, Melzack, R: Textbook of Pain. New York. Churchill Livingston, 1984: 679-690. Consider inexpensive disposable devices for ED patients

32. Leslie Zun, MD, FAAEM Cochrane Review EtiologyFindings ActivityLBPSmall beneficial effect ExerciseLBPNo indication in acute pain Bed restLBPSmall positive & small harmful Back schoolLBPEffective for chronic/recurrent Muscle relaxerLow back painEffective but with adverse effects Lumbar supportLBPUncertain The Cochrane Library. Oxford: update software.

33. Leslie Zun, MD, FAAEM Adjuncts Psychological Comfort Measures Infants Pacifier Swaddling Message Touch Sucrose solutions Distractions Distractions2-6 years Kaleidoscope Stories Bubbles Counting Pop-up toys Video games6-10 years Rusy, LM, Weisman, SJ: Complementary therapies for acute pediatric pain management. Ped Clinic NA 2000;47:589-599.

34. Leslie Zun, MD, FAAEM Adjuncts Psychological Suggestions5-10 years Magic glove or blanket Pain switch Breathing techniques _ Shallow _ Rhythmic _ Deep chest Guided imagery>4 year Music Emotive imagery Imagine special place Progressive muscle relaxation>6 years Hypnosis>4 years Rusy, LM, Weisman, SJ: Complementary therapies for acute pediatric pain management. Ped Clinic NA 2000;47:589-599.

35. Leslie Zun, MD, FAAEM Adjuncts – Parental Presence Studies have demonstrated that a majority of the parents want to stay with their child during a procedure Bauchner, H, Waring, C, Vinci, R: Parental presence during procedures in a emergency room: results from 50 observations. Pediatrics 1991; 87:544-548. Majority of pediatricians recommend that the parents be present Merritt, K, Sargent, JR, Osborn, LM: Attitudes regarding parental presence during medical procedures. AJDC 1990; 144:270-271. Patients and parents have reduced distress scores Wolfram, RW, Turner, ED: effects of parental presence during children’s venipuncture. Acad Emerge Med 1996;3:58-64.

36. Leslie Zun, MD, FAAEM Physician Compliance Drug seeking Chronic pain syndromes Pseudo-addiction Wrong focus

37. Leslie Zun, MD, FAAEM Drug Seekers 9.4% of patients who are substance addicted were from “Prescription drug” 30 patients were followed as being at risk for drug-seeking behavior: 12.6 visits per patient 4.1 different hospitals 2.2 used different aliases 2 patients died of substance abuse Zechnich, AD, Hedges, JR: Community-wide emergency department visits by patients suspected of drug-seeking behavior. Acad Emerge Med 1996; 3:312-317.

38. Leslie Zun, MD, FAAEM Drug Seekers Patients told that they would receive no more narcotics from that facility 93% received from a different hospital 71% from the same hospital Zechnich, AD, Hedges, JR: Community-wide emergency department visits by patients suspected of drug-seeking behavior. Acad Emerge Med 1996; 3:312-317.

39. Leslie Zun, MD, FAAEM Drug Seeking Indicators Frequent use of EDs Moves from one provider to another Uncoordinated care Poor follow up Difficult to prove complaints needing pain meds Treatment Consider use of agonist-antagonist Coordinated long term treatment Problematic Drug addict with acute pain

40. Leslie Zun, MD, FAAEM Calgary system to deal with patients with chronic pain who overuse the ED: Identification of patients Communication about chronic pain registry patients US system suggested many EDs keep files of habitual ED users Policies and procedures needed for these files with an approval process and quality assurance review Drug Seeking MacLeod, DB, Swanson, R: A new approach to chronic pain in the ED. Am J Emerge Med 1996;14:323-326 Goderman, JM: Keeping lists and naming names: habitual patient files for suspected nontherapeutic drug-seeking patients. Ann Emerg Med. 2003 Jun;41(6):873-81.

41. Leslie Zun, MD, FAAEM Acute on Chronic Pain Investigate reason for increased pain acute flares inadequate pain management desperation Rare tolerance to opioids Consider that the patient is depressed Need to communicate reasonable expectations for pain control Consider adding new class of pain medication or increasing dosage of current meds for acute pain

42. Leslie Zun, MD, FAAEM Pseudo-Addiction Mistaken for addiction in patients who have not been adequately treated with pain medications Drug hoarding, requesting specific drugs, drug availability, clock watching, dose escalation Aberrant behavior that disappear after effective analgesic The treating physician is responsible for appropriate and timely analgesics to control the level of pain Weissman, DE, Haddox, D: Opioid pseudoaddiction - an iatrogenic syndrome. Pain 1989;36:363-366.

43. Leslie Zun, MD, FAAEM Wrong Focus Fear of Drug Addiction 4 cases of 11,882 inpatients found to become narcotic addicted Porter, J, Jick, H:Addiction rare in patients treated with narcotics. NEJM 1980;302:123. Drug addiction is not a predictable effect and represents an adverse idiosyncratic response in psychosocially vulnerable individuals

44. Leslie Zun, MD, FAAEM Pain Perception Patient vs. care provider perception of acute pain Physicians and nurses stated lower NRS and VAS than those reported by their patients Charts review demonstrate no pain scales documentation Half the patients did not have their pain relieved in the ED on discharge Guru, V, Dubinsky, I: The patient vs. caregiver perception of acute pain in the emergency department. J Emerg Med 2000;18:7-12.

45. Leslie Zun, MD, FAAEM Pain Education Program 4-hour education program Found to increase improve the treatment of pain Curriculum Causes of pain Pathophysiology of pain Principles of pain management Types of treatment Customize treatment plan for pediatries, elderly and patients with abdomen pain Jones, JB: Assessment of pain management skills in emergency medicine residents: The role of a pain education program. JEM 1999:349-355.

46. Leslie Zun, MD, FAAEM Patients Issues Study of awareness of over the counter medication in emergency department patients Many patients were unaware about how to use OTC medication and may use them improperly Patients were often unaware of adverse effects of OTC pain meds Many patients were unfamiliar with OTCs associations with asthma, liver and kidney disease Cham, E, Hall, L, Ernest, AA, Weiss, SJ: Awareness and the use of Over-the-counter pain medications: a survey of emergency department patients. South Med J 2002;95:529-535.

47. Leslie Zun, MD, FAAEM Patient Compliance Issues Factors related to compliance Psychological factors Environmental and social factors Characteristics of a therapeutic regimen Properties of the physician-patient relations Gillum, RF, Barsky, AJ: Diagnosis and management of patient noncompliance. JAMA 1974;228:1563-1567.

48. Leslie Zun, MD, FAAEM Patient Compliance Issues Barriers to Compliance Unresolved concerns Miscommunication Regimen complexity Forms of Non-Compliance Original prescription not filled Refills not obtained Incorrect dosing Berg JS, Dischler J, Wagner DJ, Raia JJ, Palmer-Shevlin N: Medication compliance: a healthcare problem. Ann Pharmacother. 1993;27:S1-24.

49. Leslie Zun, MD, FAAEM Patient Compliance Issues Non-compliance with filling prescription at 10 days 12% of the patients did not fill their prescription Correlated with those who were uninsured 33% of the patients did not follow up with appointment Thomas, EJ, Burstein, HR, O’Neil, AC, at al: Patient noncompliance with medical advice after the emergency department visit. Ann Emerg Med 1996;27:49-55.

50. Leslie Zun, MD, FAAEM Principles of Pain Control Pain control must be individualized Anticipate pain rather than react to it Let the patient control or modulate his\her own pain Pain control is often best achieved by combination therapy including adjuncts Adapted from Jones, JB, Cordell, WH: Management of pain and anxiety in the severely injured paint. In Ferrera, PC, Colucciello, SA, Verdile, V, Et al: Trauma Management: An Emergency Medicine Approach. St Louis:Mosby;2000.

51. Leslie Zun, MD, FAAEM Patient Course The patient rated their pain a 10 out of 10 upon arrival in the emergency department The patient was given oral ibuprofen in the emergency department with little pain relief, rating their pain a 9 out of 10 The patient was given an intramuscular injection of morphine with significant pain relief, rating their pain at 3 out of 10

52. Leslie Zun, MD, FAAEM Patient Discharge Although time consuming, the patient was educated in the emergency department about how to handle their pain This education included use of non-steroidal anti-inflammatory agents round the clock for 5 days supplementing this medication with a narcotic combination agent Because the patient was a young active person, a decision was made to encourage limited activity rather than bed rest and not to add muscle relaxer to the treatment plan The patient was referred to an occupational health program for back school

53. Leslie Zun, MD, FAAEM Conclusion Use of pain assessments are valuable tools to judge pain levels and relief in the ED Consider using adjuncts in the treatment of pain in the ED Little concern over the use of aggressive pain relief in the ED ED patient discharge needs to be multifaceted

54. Questions? zunl@sinai.org ferne@ferne.org www.ferne.org 2004_saem_zun_pain_management_final.ppt