Pain Manifesto

I give a lot of pain medicine to my patients, but from everything I am reading I am not giving enough. In the last week I gave pain medicine to the following:

1. An 80 year old man with a compression fracture of the lower back. He slept all the way to the hospital.

2. A 69 year old woman with sciatica. Her 10 out of 10 pain and inability to get out of bed went down to a 5 and she was able to stand and pivot onto the stretcher, but still grimaced throughout the ride.

3. An 86 year old man with the worst abdominal pain of his life. He was still in pain, but perhaps no longer in agony. Pain went down to an 8

4. An 11 year old girl with a possibly fractured ankle. She stopped crying, and seemed sad, but calm.

I did not give morphine to:

1. A 62 year old woman in a minor motor vehicle, who claimed shoulder pain. I saw no deformity, but she seemed to have trouble moving her arm over her shoulder. She cried when we moved her off our stretcher onto the hospital’s bed.

2. A 37 year old woman with knee pain (no deformity) from a minor motor vehicle who looked me cold in the eye and told me her pain was “A ten.”

In retrospect, I should have given more to the 69 year old with sciatica, and I should have given it to the woman with shoulder pain.

My preceptee, who rode with me on a couple of these calls, when he started riding with me, was at first shocked, and then gradually came to accept and understand the need to properly medicate patients. After a call in which he failed to give pain meds to another elderly man with a compression fracture, telling me he was more conservative than me, and that the man’s pain was not that bad, and that the man did not seem to be in agony (So we now have an agony scale? I questioned later), I had him read the following powerpoint bt Dr. Bryan Bledsoe.

Why We Don’t Do a Better Job of Treating Pain

Note: It is a long download.

Fortunately our next call was the 80 year old man who also had a compression fracture, and my preceptee was able to compare the two calls and 1) the relief the patient recieved and 2) the satisfaction he recieved knowing he made the patient feel better.

I have been reading an excellent book called Pain Management and Sedation: Emergency Department Management.

It is a book intended for ER Docs, but I think any book written for an ER doc can only benefit a medic. It has some fascinating information about the damage acute pain can do to a patient.

“In addition to the obvious moral, ethical, and legal/regulatory reasons to treat pain adequately and expeditiously, failure to properly treat may make it much more difficult to treat future pain and may increase the likelihood of developing chronic pain…There is evidence that inadequate analgesia and /or sedation leads to worse clinical outcomes and more complications. A possible pathophysiologic mechanism for the negative effects of inadequate analgesia/sedation may be an excess of stress hormones causing catabolism, immunosuppression, and hemodynamic instability.”

“…Early and aggressive therapy for acute pain holds the promise of preventing or ameliorating physiologic changes that may set the stage for prolonged or chronic pain states. A great deal of work remains to be done in this area and despite these considerations, the treatment of acute pain and suffering is justified in and of itself.”

There are also chapters on opiod dependent patients and sickle cell anemia patients that will make you think twice about withholding meds on suspicion on their being drug seekers, which I will address is later postings.

I’ve been really involved in capnography lately; I think my next teaching/learning project will be pain management. I owe it to all the patients I let suffer in the past, not knowing any better.

7 Comments

  • Anonymous says:

    Have you ever used MDConsult? I drop by the hospital library now and then to peruse journals or print stuff out and signed up for an account. I saw all the ER docs using it all the time for references. This impressed me.So I signed up for an account at the hospital and, due to their site license, can use it at home with no restrictions. This is exactly what they intended, too.Anyway, today over my lunch, I happened upon two texts available online from MDConsult. They’re also in print but quite expensive I’m sure.One is “Wall and Melzack’s Textbook of Pain, 5th ed.” Brand new edition. Very thick on pain management. Geared more towards CRNAs and beyond, but still helpful.Another text I browsed for a while is “Practical Management of Pain, 3rd ed.” It’s a 2000 copyright by Mosby.Both texts are fantastic. Here’s a few snippets from “Wall and Melzack’s Textbook of Pain”. I picked these snippets because I think they refute a number of widely-held fallacies in EMS. The fallacies aren’t worth repeating, but the astute practitioner can easily determine my ulterior motive.——Because pain is subjective, the patient’s self-report provides the most valid measure of the experience.-Research on pain, since the beginning of the 20th century, has been dominated by the concept that pain is purely a sensory experience. Yet pain also has a distinctly unpleasant, affective quality. It becomes overwhelming, demands immediate attention, and disrupts ongoing behaviour and thought. It motivates or drives the organism into activity aimed at stopping the pain as quickly as possible. To consider only the sensory features of pain and ignore its motivational-affective properties is to look at only part of the problem. Even the concept of pain as a perception—with full recognition of past experience, attention, and other cognitive influences—still neglects the crucial motivational dimension.-People display and describe pain in many different ways, from stoical minimization to neurotic exaggeration. Although exceptions occur, pain, particularly chronic pain, alters daily life, often changing how the person spends his or her time. As pain continues, changes in daily life can affect family, social and work interactions, often challenging the sufferer’s sense of self and personal worth. Even with acute pain—the pain of childbirth or pain following surgery—the meaning of the pain and the emotional dimension of pain influence the description and expression of the pain, as well as what treatments the patient is willing to pursue. Given the prevalence of pain, the chronicity of many painful conditions, and the ageing population, pain clinicians and researchers alike need to pay close attention to these other responses to pain—emotional, cognitive and social responses—in addition to the pathophysiology of the condition underlying the persistent pain. Unfortunately, the assessment of the psychosocial factors discussed in this chapter is often relegated to the last resort when organic approaches and treatments have been exhausted.-Emotional distress can be conspicuous when people anticipate renewed or increased pain. Fear of pain appears to predispose severe distress, disorganized behaviour, inappropriate avoidance strategies, substantial physiological arousal, and more severe disability than would be otherwise warranted ( Asmundson et al 2004 ). There is substantial evidence that strong tendencies among chronic pain patients to fear pain, and to avoid social and physical activities associated with pain, represent major features of their problem and are associated with poorer recovery and treatment outcome. -Major barriers to opioid use continue to exist in many situations and many countries, although major progress has been made, primarily due to the relentless efforts of WHO ( World Health Organization 1986 , 1996 ). The major barriers are insufficient knowledge, inappropriate attitudes, regulatory and organizational issues, and economics. Opiophobia ( Morgan 1985 , Zenz & Willweber-Strumpf 1993 ), defined as ‘customary underutilization of opioid analgesics based on irrational and undocumented fear’, is a behaviour that is modelled, reinforced and perpetuated at all levels of the health and legal system, beginning with the attitudes of government bodies, continuing with physicians, nurses, pharmacists, and allied health professionals, and finishing with the patients, their relatives, and the general population ( Zenz & Willweber-Strumpf 1993 ).-The management of cancer pain with opioids has often been linked to hastening death in these patients. Evidence so far does not support this notion, and the indication for opioid use in this setting is clearly the provision of analgesia, not affecting survival ( Grond et al 1991 ). Opioids are used to alleviate pain and enhance comfort, and therefore obviously improve quality of life and possibly may enhance survival ( Brescia et al 1992 ).-Major barriers to opioid use continue to exist in many situations and many countries, although major progress has been made, primarily due to the relentless efforts of WHO ( World Health Organization 1986 , 1996 ). The major barriers are insufficient knowledge, inappropriate attitudes, regulatory and organizational issues, and economics. Opiophobia ( Morgan 1985 , Zenz & Willweber-Strumpf 1993 ), defined as ‘customary underutilization of opioid analgesics based on irrational and undocumented fear’, is a behaviour that is modelled, reinforced and perpetuated at all levels of the health and legal system, beginning with the attitudes of government bodies, continuing with physicians, nurses, pharmacists, and allied health professionals, and finishing with the patients, their relatives, and the general population ( Zenz & Willweber-Strumpf 1993 ).—–Here’s a few snippets from “Practical Management of Pain”.-The clinician must rely on the patient to provide information about the location, quality, and intensity of the pain. Formal teaching and daily practice prove the value of believing the patient’s description of the location and nature of the pain; nonetheless, physicians are often skeptical of the reported intensity and try to estimate the pain based on patient observation. This skepticism may result in undertreatment of pain. Attempting to gauge pain by analyzing facial expressions, responses, or changes in vital signs is of little value when caring for individuals.[3]Limited data support the widely held contention that the use of analgesics obscures the diagnosis of acute pain. As an example, judicious doses of an opioid analgesic may enhance the abdominal examination in the face of severe pain by allowing better patient cooperation. Although opioids may alter the examination,[8] localizing tenderness should be unaffected by this practice and patient comfort should be increased. Preliminary research has confirmed the safety of this approach in patients treated with opioids.[9] [10] [11] The key point is that analgesia itself should not temper the search for a cause; the physician must continue all diagnostic efforts after providing temporary pain relief.[12] If opioid interference with the physical examination is suspected, it can be reversed with naloxone. Most non-opioid analgesics (e.g., nonsteroidal agents) do not cause sedation and should not impair the examination.Even after the etiologic mechanism of acute pain is clear, pain is commonly undertreated. When the diagnosis is clear or definitive therapy is initiated or imminent (e.g., a decision to operate for suspected appendicitis, or identification of an uncomplicated fracture), analgesia should not be withheld. Similarly, simple steps to limit pain during common procedures are often omitted in the ED, yet topical anesthesia before nasogastric intubation[13] and local buffered anesthetic infiltration before vascular puncture[14] can dramatically lessen the pain of common procedures without risk.-Clinicians may withhold or underuse systemic analg
    esi
    a because of the fear of complications, especially oversedation. Although absolute dosing requirements vary in treatment of these patients, this is not a reason to withhold therapy. Furthermore, titrated doses of analgesics do not increase the risk of complications; in fact, untreated pain may be associated with increased morbidity. Dysrhythmias, myocardial ischemia, impaired host defenses, and suboptimal wound repair may result from poorly treated acute pain.[21]There are two absolute contraindications to providing systemic analgesia for a procedure: (1) the presence of clinical instability (e.g., hemodynamic, respiratory) that requires immediate attention and (2) refusal by a competent patient. Endotracheal intubation and central venous catheter insertion are examples of procedures often performed without systemic analgesia in an unstable patient. The presence of a condition that might eventually result in instability (e.g., femur fracture, pneumothorax) is not a contraindication to analgesia for a painful procedure.-Morphine (0.08 to 0.15 mg/kg increments) is the “gold standard”; most adults experience good pain relief at a total dose of 10 to 20 mg, with a duration of effect of 3 to 4 hours. Meperidine (0.75 to 1.0 mg/kg increments) is an alternative and has a duration of 2 to 3 hours; it offers no advantage over morphine but in select cases may precipitate seizures (e.g., when given in high doses or when given to patients with seizures or renal failure). Most adults undergoing a painful procedure require a total meperidine dose of 1.5 to 3.0 mg/kg.[24]-

  • PC says:

    Huge thanks for the references and quotes. I will look into these books.

  • Stacey says:

    I agree with you on your attitude toward pain managment. The only problem is my agency dosnt carry narcs right now. I hate it. Our average transport time is 30 minutes minimum (an hour and ten minutes if we go to a trauma center)It sucks having to sit there and watch some kid with a broken femur sob in agony while we bump down backroads. It also sucks having to watch someone seize for 6 minutes because you cant give him valium and its going to be another 10 before you can link up. I think it is irrisponsible to not have narcs. It is just as irrisponsible to have them but not use them.End Rant

  • PC says:

    It is shameful that your agency doesn’t carry narcs. Too few people understand just how important it is to stop pain before it can cause destruction to the body. I am going to try to put together a pain control handout — it will take awhile — but we all need to lead the cause to bring relief to our patients. Thanks for commenting.

  • Medic5 says:

    As paramedics, we frequently do under-medicate pain, as do physicians. When I became ill in the UK, the paramedics provided nitrous oxide with good results – although I did not consciously perceive pain, I did wonder who was moaning…Also, please note that if the patient presents with r/o pancreatitis, most experts suggest you avoid morphine, as it may cause/increase spasm of the Sphincter of Oddi (although there are some who dispute this). Meperedine is usually identified as the drug of choice for pancreatitis pain.

  • denvermedic says:

    thanks for posting this. i tried to go through and think of which pt. i would/would not have given pain meds to. hard to compare as so much of it for me comes down to the complete picture, especially facial expressions, easy to distract, etc.i still found your list to be fascinating, and has clearly opened up a good (and not so easy to answer) discussion.

  • PC says:

    Thanks for the heads up on pancretitis.

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