Also noticeable was the increase in dosage of analgesia from 40% to 63% and of morphine from 10% to 17% while intravenous morphine dosage increased from 2.45 to 4.6 mg. The visual analogue scale score, which is an indicator of pain, also showed a marked reduction from 2. 9 cm to 2.1 cm post training suggesting a significant improvement in pain management and patient satisfaction.[10] This cohort study clearly showed that pain management in the ED can be considerably improved by providing appropriate training for the ED staff and by implementing pain management guidelines for the ED. Addictive Personality and Psuedo Addiction

One of the major issues revolving around pain care medication is the possibility of abuse. While in most cases patients are under treated there is also a significant percentage of emergency department visits by patients who have developed an addiction to opiate analgesics and other synthetic drugs. On the other hand over suspicion and interrogation may lead to oligonalgesia leaving the patient under treated and highly dissatisfied. Identifying this drug seeking behavior from genuine patients is a big problem for the physician. However, it is necessary that the patient presenting to the ED be screened for possible drug abuse and provided substance abuse treatment. A 1996 research by Rocket et.al involved an extensive study of patients in Tennessee emergency departments. The study observed that while 23% of these patients were identified as requiring substance abuse treatment only 1% was clinically documented for alcohol or drug related problems. This shows the underreported and largely ignored nature of substance abuse problem and the largely unmet treatment requirement for substance abuse. A subsequent study by the same author analyzed the cost effects of providing abuse related treatment in the ED. It was found that Tennessee patients with unmet substance abuse treatment incurred an addition of 777 million dollars to the ED treatment costs. It was concluded that the cost of ED screening and treatment of substance abuse would be more than compensated by the cost savings resulting from the decrease in the frequency of visits to ED. [11]

The other side of the issue and the one that is vastly documented is that of pseudo addiction. Psuedo addiction as against addiction refers to the aggressive behavior of patients complaining of unrelieved pain and seeking higher dosages of drugs. One recent survey found that almost 53% of ED physicians taking care of patients with sickle cell disease suspected their patients to be addicted to opiates. Manifestation of pain due to vaso-occlusive crises is fairly common cause for ED visits in such patients. Even staggering was the fact that almost 63% of nurses reporting the prevalence of addiction among sickle cell disease patients. The result of such hesitant attitude towards opiate administration is prolonged pain and anxiety for the patient. A pain management protocol for sickle cell disease that was implemented in Philadelphia inner city hospital (as reported by Brookoff and Poloman (1992)) showed remarkable positive effect. Hospital admissions for sickle cell disease decreased by 44% and the length of hospitalization also decreased by 23%. [11] This long-term plan of pain management also served to reduce 'drug seeking behavior' in such patients. Similarly Roden et.al reported that the implementation of a pain protocol drastically improved the number of patients receiving analgesia from 9% to 31%.[12]

Treatment Modality

Pain is a complex neurobiological problem that involves the nervous system, cognitive system as well as the emotional system. No single pharmaceutical agent can provide total relief given the multiple mediators, receptors and processes involved in the experience of pain. Effective intervention would most likely be a combinational therapy that uses the varied mechanisms of action of different drugs. Most ED physicians find multimodal therapy to be optimal for pain care. Multimodal therapy involves the use of two or more methods of pain control. For example, anti-inflammatory drugs are combined...

This combinational therapy also helps to minimize the side effects and to reduce the dosage of component analgesics. Acetaminophen is a widely used synthetic analgesic with anti-pyretic properties. This is widely prescribed for musculoskeletal injuries, headaches, back pain, earache, etc.,. Acetaminophen is regarded as the safest drug for children and elders as it is well tolerated. Nonsteroidal antiinflammatories [NSAIDS] are another class of drugs widely used in the ED for pain relief. Drugs of this class work by inhibiting cyclooxygenase, the enzyme responsible for prostaglandin biosynthesis. NSAIDS have anti-inflammatory, analgesic and antipyretic properties. One serious side effect of using NSAIDS is the injury to the GI tract (possible peptic ulcer) due to the inhibition of prostaglandin. [13]
Conclusion

Given the highly subjective nature of pain, its assessment and management present a complex problem. Often in the ED much time and effort is devoted into the diagnosis of the underlying cause of pain rather than in relieving pain. A close review of the numerous pain management literature involving ED suggests that treatment and diagnosis do not proceed simultaneously in the ED and that diagnosis always precedes administration of analgesics. Optimal pain care in the ED therefore calls for a considerable change in our approach to handling a pain scenario. Relieving the patient's distress should be a high priority. To quote Albert Schweitzer, "We must all die. But that I can save a person from days of torture, that is what I feel is my great and ever-new privilege. Pain is a more terrible lord of mankind than even death itself." [12] Analgesia should be given a high priority in the ED setting. Psuedo addiction is often misinterpreted as 'Substance addiction and abuse' leading to under treatment of chronic pain. There is enough research evidence to suggest that a framework for pain management be formulated and implemented in all hospital emergency departments. This would definitely reduce patient waiting time and improve pain management outcome.

Bibliography

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