No pain, no pain

AMERICAN

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1989

No Pain, No Pain “I want to become a doctor so that I will have the privilege of using my aptitude for science to help my fellow man. ” Countless medical school applicants have used variations of this response during interviews. Nevertheless, numerous studies and recorded observations have shown that pain and suffering are commonly ignored or undertreated in most specialties of medicine. l-4 The study by Wilson and Pendleton in this issue5 confirms that emergency medicine can take its place next to other specialties in the dubious distinction of neglect and mistreatment of acute pain. Could it be that all of these purportedly caring medical school applicants were dishonest during their interviews, or do our medical school and residency training foster gross insensitivity to pain and suffering? Thinking back to my initial clinical experiences, I can vividly remember the horror I felt watching children and adults screaming out in pain while physicians and nurses blithely went about their business. After months in this environment, desensitization commonly takes place and we begin to ignore these stimuli or reinterpret them as necessary components of a patient’s unfortunate condition. One can hypothesize multiple factors involved in the widespread institutionalization of inadequate pain therapy: little clinically oriented pain education in medical schools and residencies; lack of general understanding of the basic pharmacology of the common analgesics; exaggerated fears of the side effects and abuse potential of narcotics; unproven concerns that narcotics will mask diagnoses; overgeneralization from unrewarding clinical interactions with selected pain patients (ie, chronic back pain, migraine headaches, sickle cell anemia, and pain conditions in narcotic abusers); and lack of training in the communication and interactive skills involved in the “art of Medicine.” Consideration of these hypothesized factors can direct individual physicians and the specialty of emergency medicine to abandon antiquated analgesic practices and deliver scientifically sound, humane care. Although all medical schools have basic pharmacology lectures on analgesic agents, few integrate this information in a clinically useful way. Pain has two major components: the neuroanatomic transmission and the cognitive integration and emotional reaction to the noxious stimuli. Indeed, the emotional reaction is so important to the pain experience that laboratory pain research is problematic. Most medical schools have few individuals actively involved in pain research or pain education. Even major textbooks devote little space to pain therapy. Bonica reviewed ten standard 660

textbooks on medicine and surgery published in the Unites States and found that of 13,000 total pages, only 39 were devoted to a description of the treatment of the pain associated with the numerous conditions covered such as trauma, surgery, myocardial infarctions, pancreatitis, and numerous other medical and surgical conditions6 The misuse of narcotics is a classic example of lack of application of basic pharmacological principles in attempting to relieve acute pain. Narcotics are commonly administered in the wrong doses, by the wrong routes, and repeated at the wrong frequency.1”,7 For almost all uses in acute pain, narcotics should be administered intravenously with the dose titrated to the desired effect7” The required dose may vary up to eightfold in different patients.’ The “one amp” approach of using “75 mg of Demerol IM” reflects drug packaging more than pharmacology and is clearly unsuccessful in many cases. The intramuscular route is painful and provides delayed and variable plasma levels, and its effectiveness is altered by the muscle chosen, time of day, and the particular disease state.10-‘2 As pointed out by Wilson, an “opiophobia” has developed in medicine. l3 When narcotics are administered in a monitored environment, significant side effects are relatively rare. Respiratory depression is dose dependent and easily reversible with narcotic antagonists. Studies have shown iatrogenic narcotic addiction to be a very rare result of the use of narcotics for acute pain.*,14 Some authorities have actually suggested that narcotics are safer overall than nonsteroidal antiinflammatory agents. l5 Perhaps the most common excuse for opiophobia in the emergency department is concern about masking the diagnosis. However, this theoretically reasonable concern has never been proven valid. The narcotic dose can be titrated to the point where the person is still aware of pain but is not particularly troubled by it. In this state, the physical examination should be unchanged, with the patient still able to report tenderness. Perhaps some examinations may be enhanced by improved cooperation of the patient who is not overwhelmed with agonizing pain. In any event, narcotic effects can usually be temporarily reversed with narcotic antagonists. While difficult to substantiate, physician attitudes, particularly in emergency medicine, may be skewed by antagonism caused by treating unknown, drugabusing patients in an episodic, outpatient setting. Narcotic abusers make some physicians suspicious that all patients are trying to “rip them off’ for drugs. One of my early mentors had a rule: “Give your pa-

EDITORIALS

tients the benefit of the doubt (it is better to give analgesic to five malingerers than to deny it to one patient who is truly suffering).“nj Although narcotic abusers frequent emergency departments in an attempt to obtain drugs, not all patients should be approached as abusers. Keeping files of known or suspected abusers and sharing them with local hospitals can be a helpful technique to limit abuse. To treat acute pain properly, the only accurate barometer is the verbal report of the patient. Looking for facial expressions or changes in vital signs have been shown to have little correlation with patients’ subjective sensations.7 This was well stated by Spiro: “No one feels another’s pain and physicians have to believe the patient’s words or reactions to know if he is having pain. The physician has to remind himself continually that pain, like a disease, is not an abstraction with an existence outside a person; a person must feel the pain and the complaint is the balance between cause, sensation and reaction. ” l7 Enlightened policies can be written to guide analgesic use in some of the conditions commonly associated with an adversarial relationship (low back pain, sickle cell vaso-occlusive crisis, migraine headache, etc). A poignant example of deplorable analgesic practices exists in emergency departments, where procedures are frequently performed on children with “Brutane” (the total immobilization of the screaming child with the use of several adults and a papoose). Once the child is immobilized, procedures are performed with little or no analgesia. Animal rights legislation has outlawed these very same procedures unless appropriate analgesic techniques are used-how can we make excuses such as children “don’t remember” or “are too fragile to receive potent pharmacologic agents”? The “art of medicine” can frequently be as important as the science in the treatment of pain. A patient’s expectations are formed early in a therapeutic encounter and greatly influence the success of any intervention. A positive, caring, friendly, professional approach to a patient can allay anxiety and improve the effectiveness of any analgesic attempt. To distract the patient with speech can be particularly comforting to patients. All too commonly, patients are allowed to see threatening equipment being prepared while physicians try to relieve the patients’ anxieties with poorly chosen terms such as hurt, prick, and bee sting. This concern certainly isn’t new. The dean of the Harvard Medical School addressed the graduating class in 1926, “The most common criticism made at present by older practitioners is that young graduates have been taught a great deal about the mechanism of disease but very little about the practice of medicine, or to put it more bluntly, they’re too scientific and do not know how to take care of patients. ”

The most succinct advice is to follow the Golden Rule-treat pain and suffering in the same way you would want it to be treated in yourself. Pain should be approached with the same vigor that we attack other medical and surgical emergencies, but tlhis does not mean that potent analgesics can be used haphazardly without caution. As with all interventions, significant morbidity and even death can result from careless use of pharmacological agents, even topical ones.” Perhaps we should take a lesson from modern dentistry, which has taken huge strides in the safe elimination of pain from its practice. If the financial success of physicians were more dependent on their analgesic techniques, perhaps we too would improve our analgesic practices. A wealth of opportunity exists for emergency physicians to contribute vital research in the treatment of acute pain: the role of agonist-antagonist narcotics; the effectiveness of adjunctive agents such as hydroxyzine; newer routes of narcotic administration, including transdermal, transmucosal, and intraspinal; use of patient-controlled analgesia; indications for transcutaneous electrical nerve stimulation; use of ketamine and its individual isomers; use of hypnosis and guided imagery; newer techniques of local anesthesia; and better-defined indications for use and choice of oral narcotic and nonnarcotic analgesics. Emergency medicine has a particularly exciting opportunity to foster research and education in the treatment of acute pain. Few missions in medicine can be considered more noble than the relief of pain and suffering using modern and effective analgesic drugs and techniques. Nevertheless, acute pain continues to be poorly treated in most specialties, including emergency medicine. In our society, it is very common for those invoilved in athletic and competitive endeavors to use the mantra “no pain, no gain.” For physicians treating patients in acute pain, however, a more appropriate mantra would be “no pain, no pain.” M. PARIS, MD University of Pittsburgh Pittsburgh, Pennsylvania PAUL

REFERENCES 1. Marks RD, Sachar EJ: Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med 1973;78:173-181 2. Perry S, Heidrich G: Management of pain during debridement: A survey of US burn units. Pain 1982;13:267-280 3. Sirwatanakul K, Weis 0, Alloza JL, et al: Analysis of narcotic usage in the treatment of postoperativme pain. JAMA 1983;250:926-929 4. Mather L, Mackie J: The incidence of postoperative pain in children. Pain 1983;15:271-282 5 Wilson JE, Pendleton JM: Oligoanalgesia in f:he emergency department. Am J Emerg Med 1989;7:620-623 6. Bonica JJ: Biology, pathophysiology, and treatment of acute pain. In Lipton S, Miles J (eds): Persistent Pain: Modern 661

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7, Number

Methods of Treatment, voi 5. London, Grune & Stratton, 1985, pp 1-32 7. Perry S: Using narcotic analgesics to optimum effect: A modern view. EM Rep 1982;3:91-96 8. Goldman B, Stewart sedation in the 1989;10:73-81

RD: Providing effective analgesia and emergency department. EM Rep

9. Tamson A, Har-tvig P, Fagerlund C, et al: Patient-controlled analgesic therapy. Part II: Individual analgesic demand and analgesic plasma concentrations of pethidine in postoperative pain. Clin Pharmacokinet 1982;7:164-175 10. Grabinski PY, Kaiko RF, Rogers AG, et al: Plasma levels and analgesia following deltoid and gluteal injections of methodone and morphine. J Clin Pharmacol 1983;23:48-55

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sition and pain relief after IM administration of meperidine during day or night. Int J Clin Pharmacol Ther Toxicol 1983;21:218-223 13. Morgan JP, Kagan DV: Society and Medication: Conflicting Signals for Prescribers and Patients. Lexington, MA, Lexington, 1985 14. Porter J, Jick H: Addiction rare in patients cotics. N Engl J Med 1980;302:123

with nar-

15. Halpern LM: Drugs in the management of pain: Pharmacology and appropriate strategies for clinical utilization. Adv Pain Res Ther 1984;7:147-172 16. Geiderman J: Pharmacology 1986;8:viii

update.

Topics

pain and perfectionism-The patient.” N Engl J Med

11. Abbuhl S, Jacobson in patients with 1986;15:433-438

S, Murphy JG, et al: Meperidine usage sickle cell crisis. Ann Emerg Med

17. Spiro HM: Visceral viewpoints physician and the “pain 1976;294:829-830

12. Ritschel

G, Ford DJ, et al: Pilot study on dispo-

18. Dailey RH: Fatality secondary to misuse Ann Emerg Med 1988;17:159-160

WA, Bykadi

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of TAC solution.

International Emergency Health Care Development Trauma and other medical emergencies constitute a major global health problem, and all primary medical care systems need to have some mechanism for responding to health emergencies. To address these issues, the International Conference on Emergency Health Care Development was held in the Washington, DC, metropolitan area, August 15 through 18, 1989. This conference, developed by Medical Care Development International and sponsored by the US Public Health Service, the World Health Organization, the Pan American Health Organization, the Office of the United Nations Disaster Relief Coordinator (UNDRO), the United Nations International Children’s Emergency Fund (UNICEF), the US Department of Transportation, and the US Agency for International Development, provided a major international forum on design, methodology, and implementation of projects in emergency health care development in both industrialized and less developed parts of the world. Presentations focused on the development of both prehospital and in-hospital emergency health care systems for everyday emergencies as well as natural and technological disasters. A central theme of the conference was the necessity to view emergency health/ medical response capability as a natural part of every national primary health care plan. Another major purpose of the conference was to launch in-depth discussion of emergency health care planning goals within the framework of the recent designation by the United Nations General Assembly of the 1990s as the International Decade for Natural Disaster Reduction.

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The conference involved the participation of over 500 persons from 80 developed and developing countries. Participants included ministry-level decision makers, emergency medical and disaster management planners, and clinicians at the implementation level. Discussion centered on processes and concrete methods for developing or improving emergency health care capacity within societies with widely differing characteristics and resources. Specifically, the participants were encouraged to focus their work on different ways to build local resources into systems of response for health emergencies and to integrate them with existing health plans and the operations of other public safety agencies at ascending levels of need. There were interesting presentations from several less developed countries that have built or created effective emergency health care systems with extremely limited economic resources. International sources for health system financing were also presented by several development agencies such as USAID and the InterAmerican Development Bank. A recurrent theme during the 4-day conference was the need to integrate routine emergency health care requirements into planning for both national primary health care and disaster response systems. The conference consisted of a mix of plenary and workshop sessions. Workshops focused on such topics as Rural Emergency Health Care, Rural Highway Trauma, Emergency Health Care for Displaced Populations, Mobile Emergency Communications, The Epidemiology of Emergency Health Care, and “Urban Search