giving Narcotics like candy

[Sassafras]

Buncha damn druggies! (j/k)

[Dustdevil]

Anybody who thinks tramadol isn't an effective analgesic simply isn't taking enough of it! :twisted:

[Asysin2leads]

Carisoprodol (Soma). Got some of that for my back round I. To rip off Denis Leary, "It said on the label 'May cause drowsiness'... it shoulda said 'Don't make any f---ing plans'! "

[Dustdevil]

"It said on the label 'May cause drowsiness'... it shoulda said 'Don't make any f---ing plans'! "

LMAO! I like that!

Very true too!

[Airmedic999]

I gave her 7.5mg IM protocol is 5-15mg (could not get a line) I did not want to totally snow her. It worked well. we also carry demeroll, fentanyl

but protocol is longer than 20 min transport time go with morph.

Interesting that you use Fentanyl in over there. Nice drug with few side effects. I presume you give the fentanyl for anything less than 20 minutes journey to emergency department...i.e. they will be needing more analgesia when they arrive or shortly thereafter. What is your max amount - presumably up to about 100mcg is it?

[Airmedic999]

Anybody who thinks tramadol isn't an effective analgesic simply isn't taking enough of it! :twisted:

I use Tramadol sometimes. Does not seem like a bad drug on the whole. The main probs are the fact that in the UK it's not licenced for paeds and needs good anti - emetic cover

[Ace844]

Hi All,

Here's yet another study which shows that we aren't the only clinicians who are biased and how our opinions and prejudices can affect our patients....

(Acad Emerg Med Volume 13 @ Number 2 140-146,

published online before print January 25, 2006, doi: 10.1197/j.aem.2005.08.008

[u)

CLINICAL INVESTIGATION

Patient and Physician Perceptions as Risk Factors for Oligoanalgesia: A Prospective Observational Study of the Relief of Pain in the Emergency Department

James Miner, MD, Michelle H. Biros, MS, MD, Arleigh Trainor, MD, Daniel Hubbard, BA and Maryam Beltram, MD

From the Department of Emergency Medicine, Hennepin County Medical Center (JM, MHB, AT, DH, MB), Minneapolis, MN.

Address for correspondence and reprints: James R. Miner, MD, Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue S, Minneapolis, MN 55415. Fax: 612-904-4640; e-mail: miner015@umn.edu .

]

ABSTRACT

Objectives: Previous studies have reported that pain is undertreated in the emergency department (ED), but few physician-dependent risk factors have been identified. In this study, the authors determine whether pain treatment and relief in ED patients are negatively associated with the physician's perception of whether the patient was exaggerating symptoms, and with the patient and physician's perceptions of the interaction between them, as well as whether demographic characteristics were associated with these perceptions.

Methods:This was a prospective observational study of patients who were undergoing treatment for painful disorders in the ED. Before treatment for pain, patients were asked to complete a 100-mm visual analog scale (VAS) describing their pain. Demographic information and pain treatments administered were recorded. Patients completed a second pain VAS before discharge from the ED. Patients were then asked to complete three queries describing their perception of their interaction with the physician. After the patient had left the department, the patient's physician was asked to complete a query describing his or her perception of the interaction and to complete a VAS describing how likely it was that the patient was exaggerating symptoms to obtain pain medicines for nonmedical purposes.

Results: There were 1,695 patients enrolled in the study; 32 patients were excluded because of missing or incomplete data, leaving 1,663 for analysis. Of these patients, 71.9% received a pain medication while in the ED. There was no association between the physician's VAS for perceived exaggeration of symptoms, the queries describing physician–patient interactions, and patient ethnicity and whether patients received pain treatment in the ED. There was a negative correlation between the physician's VAS for perceived exaggeration of symptoms and the change in the patient's pre- and posttreatment pain VAS scores. The physician's VAS score for perceived exaggeration of symptoms was higher among Native American patients than among other ethnic groups (p 0.001). The patient and physician queries rating their interaction show a decreased absolute reduction of VAS pain scores (p 0.001) and a reduction in the number of patients having at least a 50% reduction in their pain VAS score when interactions were rated "bad" and "very bad" (p 0.001).

Conclusions: The physician's perception of whether a patient was exaggerating symptoms was associated with the patient's ethnic background and with both the physician's and patient's perception of their interaction. These perceptions were negatively associated with the achievement of pain relief and the change in the patient's pain VAS scores, but not with whether a patient was treated with a pain medication.

Key words: emergency medicine; pain; analgesia; pain treatment; ethnicity; physician relations

INTRODUCTION

It is known that patients often receive inadequate analgesia in the emergency department (ED).1,2 It has been suggested that differences found in the quantity of pain medications given and the amount of relief achieved are based on patient characteristics, such as ethnicity or race, gender, age, and insurance status.3,4 It also has been suggested that patient's expectations for treatment of pain and patient's perception of pain do not differ among ethnic groups when patients are matched for socioeconomic factors.5,6,7,8,9 Differences have been noted, however, in the way that patients of different cultural backgrounds express their pain.8 Differences in the interactions of physicians with patients of a different ethnic group have been described10 and may affect physician assessment.11 When affect, actual patient–physician interaction, and cultural expressions of ethnicity are removed from a case presentation, such as with written clinical vignettes, patients with similar pain are similarly treated by physicians.12 Cultural discordance between the patient and the physician may hinder the ability of patients to confer an understanding of their pain to their physician.

The treatment of pain is dependent on the physician's accurate assessment of the patient's pain. In fact, the physician's assessment was the only predictor of pain treatment that Bartfield and colleagues13 found for patients with back pain, regardless of the patients' ethnicity, age, or insurance status. It is possible that disparities in the treatment of pain come from variations in assessment rather than from variations in treatment among patients who are assessed as having a similar degree of pain. Because pain cannot be objectively measured, a physician's assessment is dependent on his or her communication with the patient, including both verbal and nonverbal cues to confer an appreciation of the patient's pain. Unfamiliar or unrecognized cues between the patient and physician may be misinterpreted, leading to a poor transfer of information between the two.

It is possible that the emergency physician may interpret the incorrect or inadequate information regarding pain that the patient is providing as an exaggeration of the patient's symptoms, or as patient misrepresentation to obtain pain medications.

The influence of cultural background and socioeconomic group on the way that a physician assesses a patient's pain is multifactorial,4 including factors stemming from not only the patient but also the physician. In this study, we sought to determine whether pain relief in ED patients is negatively associated with the physician's perception of whether the patient was exaggerating symptoms, or with the patient and physician's perception of the interaction between them, and whether demographic characteristics were associated with these perceptions.

METHODS

Study Design

This was a prospective observational study of patients undergoing treatment for painful disorders in the ED between January 15, 2003 and January 15, 2004. The institutional review board of Hennepin County Medical Center approved the study. Patients provided informed consent before enrollment.

Study Setting and Population

This study was performed at Hennepin County Medical Center, an urban county medical center with approximately 93,000 patient visits per year. The study was conducted when a research assistant was available (usually about 112 hr/wk, 7:00 AM to 11:00 PM). All adult (age 18 yr) ED patients who were undergoing treatment for a painful disorder that could be classified as extremity pain, back pain, headache, neck pain, abdominal pain, or dental pain were eligible for study enrollment. Patients were excluded if they were unable to give consent, had clinical evidence of intoxication before enrollment, had received a pain medication before enrollment, or had entered the study previously.

Study Protocol

Before treatment for pain, patients were asked to complete a 100-mm visual analog scale (VAS) that had "most pain imaginable" on one end and "no pain" on the other. The time that the patient waited to be placed in a room in the ED (i.e., triage time) and the time to the administration of the first pain medication were recorded. The patient was asked his or her age, occupation, highest level of education obtained, ethnicity, and whether English was the first language he or she had ever learned. Pain medications given to the patient at any time during the ED visit were recorded. Before discharge from the ED, the patient was asked to complete a second VAS on a separate sheet of paper to describe his or her pain level after treatment. Patients were then asked three queries. The first was, "How would you rate your interaction with the doctors who took care of you today?" The second was, "How well do you think the doctors taking care of you understand your pain?" The third was, "How would you rate your previous interactions with physicians?" Possible responses to all queries were as follows: very good, good, average, bad, and very bad. All discharge prescriptions were recorded.

After the patient had left the department, the patient's physician was asked to complete the query, "How would you rate your interaction with this patient?", with the same possible responses as above. The physician then was asked to complete a visual analog scale to answer the query, "How likely do you think it is that this patient is exaggerating his or her symptoms in order to obtain pain medicines for non-medical purposes?", with "unlikely" on one end and "probable" on the other.

Data Analysis

Data were collected by a designated research assistant and were entered in an Excel (Microsoft Corp., Redmond, WA) database for further analysis. All analysis and interpretation of data was performed by using Stata 6.0 (Stata Corp., College Station, TX) statistical software. Descriptive statistics with 95% confidence intervals (95% CI) were used when appropriate.

The change in VAS scores was compared between groups in two ways. The absolute change in VAS scores over the course of the ED visit between groups based on ethnicity, occupation, education level, and the queries describing the interaction were compared by using analysis of variance.14 The changes in the pain VAS scores also were converted into dichotomous data for patients who had at least a 50% reduction in their VAS scores and those who did not. These were then compared between groups by using chi-square statistics. The data were analyzed by these two different methods to assess the presumed clinical significance of the findings and to report them in a clinically relevant manner. The VAS score measuring the physician's perception of whether a patient was exaggerating symptoms was compared in two ways between groups: by using Spearman rank correlation, and dichotomously, by using chi-square tests to assess patients with scores 15 mm and with scores > 15 mm. Pain medications given were classified by the investigators as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen, oral narcotics, parenteral narcotics, and local anesthesia. Patient occupations were classified by the investigators as nonprofessional, professional, self-employed, student, and retired, on the basis of patient's response.15 Education levels were classified by the investigators as graduate school, college, high school, secondary school, and none, on the basis of patient's response.

Power analysis showed that to find a correlation coefficient of 0.1 between the VAS scale for the physician perception of the exaggeration of symptoms and the absolute change in VAS pain scores for patients, using a beta of 0.1 and an alpha of 0.01, 1,481 patients would be required.

RESULTS

There were 1,695 patients enrolled in the study. Thirty-two patients were excluded because of missing or incomplete data; 1,663 patients remained for analysis. We did not collect any data on those who were approached and declined participation. The mean age of the enrolled was 37.5 years (SD ± 37.4 yr; range, 18–89 yr), and 56.8% were male. The mean time in the waiting room (triage time) was 38.4 minutes (± 40.9 min; range, 0 to 339 min); the mean time to delivery of the first pain medication (for patients who received a pain medication) was 78.4 minutes (± 53.1 min; range, 0 to 326 min). The mean total time in the ED was 153.6 minutes (± 100.1 min; range, 15 to 722 min). Seven hundred forty-eight patients presented with pain in an extremity, 399 with back pain, 200 with abdominal pain, 133 with dental pain, 133 with neck pain, and 50 with headaches. The mean pain VAS score of all patients on initial presentation was 71.1 (95% CI = 69.9 to 72.2). The mean pain VAS of all patients on discharge was 54.4 (95% CI = 52.9 to 55.8). Four hundred sixty-seven (28.1%) patients had a least a 50% decrease in their pain VAS score while in the ED.

One thousand one hundred and ninety six (71.9%) patients received pain treatment in the ED. Sixty-six patients received local anesthesia, 234 received an NSAID or acetaminophen, 670 received an oral narcotic, and 215 received a parenteral narcotic. There was no difference in the number of patients treated for pain when patients were compared by ethnic group (p = 0.97). The mean presenting pain VAS score for patients who received treatment for pain was 72.4 mm (95% CI = 71.2 to 73.7), and it was 67.5 (95% CI = 65.2 to 69.9) for those who did not (p = 0.00).

Seven hundred forty-nine (45%) patients described themselves as African American, 632 (38.0%) as white, 145 (8.7%) as Native American, 105 (6.3%) as Hispanic, and 19 (1.1%) as Asian. Pain VAS scores and pain relief are described by ethnic group in Table 1. There was no difference in the number of patients treated or in the change in VAS scores when compared by ethnicity. Fewer Native American patients obtained a 50% reduction in their pain VAS score compared with patients in other ethnic groups (Table 1, p = 0.05). Results based on patient-described occupation and education are listed in Tables 2 and 3. Patients who designated English as their first language achieved a 50% reduction in their pain VAS 27.2% of the time (414/1,521), and patients who did not designate English as their first language achieved a 50% reduction 37.1% (53/143) of the time (p < 0.001).

The overall mean VAS score for the physician's perception of exaggeration of symptoms to obtain medication was 19.8 mm (95% CI = 18.5 to 21.0). There was a negative correlation between the physician's VAS for perceived exaggeration of symptoms and the change in the patient's pre- and posttreatment pain VAS scores (Spearman's = –0.07, p = 0.003). The VAS for perceived exaggeration of symptoms also correlated negatively with patients achieving greater than 50% reduction in posttreatment pain VAS scores (Spearman's = –0.05, p = 0.0003). The physician's VAS for perceived exaggeration of symptoms for patients who had a 50% reduction in pain scores after treatment was 15.5 mm (95% CI = 13.5 to 17.5); for those patients who did not achieve at least a 50% reduction in pain, the mean was 21.4 mm (19.8 to 24.0; p = 0.000). The physician's mean VAS for perceived exaggeration of symptoms for patients who received treatment for pain was 19.4 (95% CI = 18.0 to 20.9), and for those who did not receive any treatment, the VAS was 20.7 mm (95% CI = 18.3 to 23.1; p = 0.36).

Patients were divided into two groups on the basis of the physician's VAS for perceived exaggeration of symptoms to obtain medications: those with a VAS of 15 mm (n = 1,112; mean, 5.1 mm; 95% CI = 4.7 to 5.4) and those with a physician's perception VAS of >15 (n = 551; mean, 49.4 mm; 95% CI = 47.4 to 51.5). The mean change in the pain VAS score for the group not perceived to be exaggerating (physician's perception VAS 15 mm) was 24.0 (95% CI = 20.1 to 29.2), and for the group that was perceived to be exaggerating (physician's perception VAS > 15), it was 14.1 (95% CI = 1.0 to 27.2, p = 0.064). The rate of 50% pain relief was 30.5% in the group not perceived to be exaggerating and was 21.0% in the group perceived to be exaggerating (p 0.001).

The patient queries rating their previous interactions with physicians, their current interaction with their physician, and how well they felt the physician understood their complaint compared with pain treatment, pain relief, and the physician perception of exaggeration are described in Table 4. No difference was found in the number of patients who received treatment, but differences were found in pain VAS changes and the physician's perception of exaggeration. The physician's impression of the interaction relative to pain treatment, pain VAS changes, and the perceptions of exaggeration are described in Table 5. Differences in pain VAS changes and the perception of exaggeration of symptoms are noted here as well.

DISCUSSION

The question of why ED treatment disparities exist between groups of patients is not easily answered, but the definition of some of the factors that influence disparities will allow improvements in emergency care. Demographic, language, and cultural discordance between physicians and patients may make it difficult for patients to express themselves in terms to which the physician can relate. It is possible that misinterpreted information from the patient's description of history that does not correspond to the objective information that a physician has obtained may lead to the misperception that a patient is exaggerating symptoms to obtain pain medicines.

To assess which patients reported relief of their pain, we used both the change in the pain VAS score, and a cutoff of a 50% decrease in patient's posttreatment VAS. Our data indicate that this goal of pain relief was not frequently achieved. In fact, we also observed that only 71% of patients complaining of pain received any pain treatment in the ED. Even if pain treatment was given, it took a mean of 40 minutes beyond triage to do so. These results imply that pain was often underassessed or undertreated. Unfortunately, similarly low rates of pain relief have been reported before.1,2,16

These observations cannot be explained by differences in initial pain experienced by patients. The presenting pain VAS score that we measured was only slightly higher among patients who were treated for pain than in those who were not, and although the absolute numbers were statistically significant, they were not clinically significantly different. The factors that we measured in this study did not appear to affect the number of patients who received a pain medication, but they did affect the degree of pain relief that patients reported.

The number of patients who reported a 50% decrease in pain was similar among all groups except for Native Americans, in whom it was lower (21.4%). Native American patients also had the highest VAS score for perceived exaggeration of symptoms to obtain medicines. We also noted that patients who were perceived as exaggerating symptoms had a lower percentage change in the pain VAS score in response to treatment, and that fewer achieved a 50% decrease in their pain VAS score. When the patient or the physician perceived the interaction to be poor, physicians suspected that the patients were exaggerating their symptoms, and patients had less pain relief. The fact that the patient's and the physician's perception of the encounter, as well as the physician's perception of exaggerated symptoms, are all associated with pain relief suggests that these factors are associated with one another.

The decision to treat pain and a physician's interpretation of a patient's pain are largely subjective and require detailed interaction between the patient and the physician. Our results suggest that physician perception of patient exaggeration of symptoms to obtain pain medications is associated with patient's reported pain relief. Because of the painful natures of the pathologies we included and our large number of patients enrolled, we believe that it is very unlikely that a majority of patients truly were purposefully providing inaccurate information to obtain pain medications. Further, the observation of a difference in the physician's perception of exaggeration of symptoms among ethnic groups, and the correlation of the patient's perception of a good physician–patient interaction and pain reduction with the perception of exaggerated symptoms, suggests that this perception is related to the social interaction during the physician–patient encounter.

We have identified two related predictors of oligoanalgesia: the patient and physician's perception of their interaction, and the physician's perception of whether a patient is exaggerating symptoms to obtain pain medications. It is possible that the patient's perception of the interaction is associated with pain relief, because patients who get along with their doctors feel better because of the interaction. In fact, our data show that the degree of pain relief was not different between those who were treated and those who were not. This could suggest that treatments were not effective, that the patients were generally undertreated, or that, considering the pain relief reported by untreated patients, other factors, such as pleasant patient–physician interactions, may contribute to a patient's perception of pain relief. Another possible explanation is that when a patient feels that he or she is not getting along with his or her doctor, that patient's attempts to alter the situation to improve the chance of getting pain relief may be inaccurately interpreted by the physician as the exaggeration of symptoms.

There is no doubt that drug-seeking behavior exists, but the exact rate at which it occurs is unknown. There are clear objective signs, but it is largely the subjective determination that the patient is trying to obtain pain medicine that is not truly needed. The fundamental question for the physician is which is worse: to treat the patient with pain medications who does not need them, or to not treat the patient who needs pain medications but whose behavior and interaction with the physician may suggest drug seeking? This question must be answered on a case by case basis for each physician, but simply by asking the question, the problem that the patient faces can be better addressed.

LIMITATIONS

It is very likely there are multiple unmeasured confounders affecting the results that we have described here. Our simple design attempted to measure data related to a single aspect of a patient–physician interaction by using very specific questions that were likely to be variably interpreted by the subjects. These questions were used as surrogates to allow estimates of factors that we could not measure or detect in this study. Furthermore, this study was performed at a teaching facility, and both a resident and attending physician were involved in each patient's care; the physician measurements, however, were only obtained for the physician who was primarily assigned to care of the patient. Confounders, such as time in department, time of day, and the general care that a patient has received, all undoubtedly affect a patient's impression of the interaction with the physician.

After completion of the study, we noted that the VAS scores for physician perception of exaggeration of symptoms to obtain medicines did not distribute normally, and we chose to modify our planned analysis by further analyzing the data in two groups: physician perception VAS scores of >15 mm versus VAS perception scores of < 15 mm. We felt that this compared those patients whom the physician did not consider to be exaggerating with those whom the physician felt were exaggerating.

CONCLUSIONS

Physician perception that a patient was exaggerating symptoms to obtain pain medications was associated with Native American ethnicity and with both the physician's and patient's perception of their interaction. This perception was negatively associated with the achievement of the patient's pain relief and with the change in pain in the patient's VAS scores, but not with whether a patient was treated with a pain medication. This suggests that the nature of the interaction between the physician and the patient is a source of factors leading to oligoanalgesia. This may represent an area in which pain management in the ED could be improved beyond simply increasing the distribution of pain medications.

FOOTNOTES

Presented in part at the annual meeting of the Society for Academic Emergency Medicine, Orlando, FL, May 2004.

A related Commentary appears on page 191.

REFERENCES

1. Wilson JE, Pendleton JM. Oligoanalgesia in the emergency department. Am J Emerg Med. 1989; 7:620–3.[CrossRef][Medline]

2. Rupp T, Delaney KA. Inadequate analgesia in emergency medicine. Ann Emerg Med. 2004; 43:494–503.[CrossRef][Medline]

3. Todd KH. Pain assessment and ethnicity. Ann Emerg Med. 1996; 27:421–3.[Medline]

4. Lasch KE. Culture, pain, and culturally sensitive pain care. Pain Manage Nurs. 2000; 1(3 Suppl 1):16–22.

5. Edwards RR, Moric M, Husfeldt B, Buvanendran A, Ivankovich O. Ethnic similarities and differences in the chronic pain experience: a comparison of African American, Hispanic, and white patients. Pain Med. 2005; 6:88–98.[CrossRef][Medline]

6. Zatzick DF, Dimsdale JE. Cultural variations in response to painful stimuli. Psychosom Med. 1990; 52:544–57.[Abstract/Free Full Text]

7. Pfefferbaum B, Adams J, Aceves J. The influence of culture on pain in Anglo and Hispanic children with cancer. J Am Acad Child Adolesc Psychiatry. 1990; 29:642–7.[Medline]

8. Greenwald HP. Interethnic differences in pain perception. Pain. 1991; 44:157–63.[CrossRef][Medline]

9. Lee WW, Burelbach AE, Fosnocht D. Hispanic and non-Hispanic white patient pain management expectations. Am J Emerg Med. 2001; 19:549–50.[CrossRef][Medline]

10. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999; 282:583–9.[Abstract/Free Full Text]

11. Tait RC, Chibnall JT. Physician judgments of chronic pain patients. Soc Sci Med. 1997; 45:1199–205.[CrossRef][Medline]

12. Tamayo-Sarver JH, Dawson NV, Hinze SW, et al. The effect of race/ethnicity and desirable social characteristics on physicians' decisions to prescribe opioid analgesics. Acad Emerg Med. 2003; 10:1239–48.[Abstract/Free Full Text]

13. Bartfield JM, Salluzzo RF, Raccio-Robak N, Funk DL, Verdile VP. Physician and patient factors influencing the treatment of low back pain. Pain. 1997; 73:209–11.[CrossRef][Medline]

14. Farrar JT, Portenoy RK, Berlin JA, Kinman JL, Strom BL. Defining the clinically important difference in pain outcome measures. Pain. 2000; 88:287–94.[CrossRef][Medline]

15. Burton NW, Turrell G. Occupation, hours worked, and leisure-time physical activity. Prev Med. 2000; 31:673–81.[CrossRef][Medline]

16. Hostetler MA, Auinger P, Szilagyi PG. Parenteral analgesic and sedative use among ED patients in the United States: combined results from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 1992–1997. Am J Emerg Med. 2002; 20(3):139–43.[CrossRef]

Received for publication June 13, 2005. Revision received August 11, 2005. Accepted for publication August 13, 2005

Food for thought

Hope this helps,

ACE844

[ffpm41]

I am the candy man, to a certain degree. Anyone of us who has been in Px understands how uncomfortable it can be, and why not do for others like you would want done for you. My requirements for how much to use are:

1) Keep em breathing

2) Keep em happy

3) Follow the protocol.

A medicated Pt is a happy Pt, plus who said you have to knock off the Px in all situations, you can help take the edge off if that's all you can do.

[medik8]

Also, most diabetics do not have feel chest pain during an MI. I have seen this first hand on many occations while working in a dialysis center.

Very true...Because I knew this....I was able to save my own father.

8

[mizzoumedic74]

Many ER physicians do not actually know what happens in field emergency medicine. If you act in the best interest in your patients and stand behind that...you will never go wrong. Our protocol has standing orders for Fentanyl (1mcg/kg initial; 0.25mcg q 5 mins as necessary for pain control). The great thing found with Fentanyl is the rapid onset and short duration. It is a quick alleviator of pain and yet, does not drop the BP like MSO4.