Minneapolis—Contrary to common belief, the best way to determine if a patient in the emergency department (ED) needs analgesics is simply to ask if he or she wants more pain medication, rather than using pain scores, according to an emergency medicine pharmacist who led an educational session at the American Society of Health-System Pharmacists 2013 Summer Meeting.

Scores on the standard 11-point Numeric Pain Scale can be factored in to the decision, but “I don’t think it is something that you should rely on entirely. You can get the score, but it shouldn’t determine whether you treat,” said Asad Patanwala, PharmD, an associate professor at the University of Arizona College of Pharmacy, in Tucson.

What does count is whether patients say yes or no when asked if they would like pain medication, he said. A recent study of nonelderly ED patients with acute severe pain revealed a significant drop in the need for additional pain relief at 60 minutes among those treated with the patient-driven 1+1 protocol (1 mg of IV hydromorphone followed by a second 1 mg dose 15 minutes later) compared with those who received physician-driven doses of IV opioids (92.3% vs. 76.6%; P<0.05) (Ann Emerg Med 2011;58:352-359).

Based on these findings, Dr. Patanwala encouraged ED pharmacists to recommend a patient-driven approach to pain management in the ED at their institutions. “It’s more intuitive just to ask this simple question,” he said in an interview. Furthermore, the standard 11-point scale may not be as reliable a method because patients may be more likely to give the pain score they believe the clinician wants to hear in order to get pain medication. Pain scores vary based on history and previous experience, and some patients report a high score even if they really don’t want medication or a low score when pain relief actually would be necessary.

Nicole M. Acquisto, PharmD, BCPS, an emergency medicine specialist at the University of Rochester Medical Center, in Rochester, N.Y., said pain management in the ED at her institution is patient-driven, and that the system works well. Pain control is discussed at the initial evaluation. If needed, the patient is given an initial dose of medication, the physician writes a standing as-needed order for medication, and additional doses are administered on nurse evaluation and patient request.

The problem with a physician-driven approach, she said, is that “the provider may evaluate the patient’s pain and there may be a delay in entering a single pain medication order because the provider is taking care of several patients. Also, after the order is entered, the nurse may be taking care of several patients as well. There can be additional delays in the time to acknowledge that order and administer the medication, which ultimately creates a significant delay in the time it takes for patients to receive adequate pain relief,” she said.

Dr. Patanwala encouraged pharmacists to support the timelier and appropriate administration of analgesics in the ED, where pain intensity is high but pain medication appears to be underused. The results of a prospective, multicenter study of 842 ED patients (median pain score of 8/10) showed that only 60% of patients received pain medication, and that the median time to receive that medication was 90 minutes, he noted. Among the patients who did not receive analgesics, 42% wanted them, but only 31% voiced their requests (J Pain 2007;8:460-466).

According to Dr. Patanwala, the optimal pain management strategy in the ED is one of titration based on three factors—time to achieve analgesia, time to reach peak analgesic effect and duration of effect. These factors are underappreciated or misunderstood in many EDs, he said. “For example, there is a misconception out there that once you give someone morphine, they have instant pain relief. That’s not true. The onset could take several minutes, rather than seconds, and the peak effect isn’t for 15 minutes.” For this reason, at his institution, a level 1 trauma center, Dr. Patanwala and his colleagues use fentanyl instead of morphine for severe pain when rapid onset is required. “In most trauma patients, that’s all we use initially,” he said.

Recent research also is calling into question the common ED practice of basing opioid dosages solely on patient weight, he said. A study by Dr. Patanwala and his colleagues at the University of Arizona Health Center of 50 opioid-naive patients showed that morphine dosing based on weight was not necessary to achieve pain relief. Patients received a fixed single dose of 4 mg of morphine regardless of weight on presentation in the ED. Pain was assessed at baseline and at 15 and 30 minutes. Patient weight was not significantly associated with the level of patients’ responses to morphine on an 11-point verbal numerical scale (J Opioid Manage 2012;8:51-55).

“The first thing clinicians often look at is the size of the patient, and based on that one variable, they start recommending larger or smaller doses of morphine. Our thinking is that a lot of different factors can predict someone’s response. We don’t know what all of those factors are, but contrary to common wisdom, it’s not just weight,” Dr. Patanwala said. A smaller person with a history of chronic pain may have a higher tolerance to opioids and not achieve sufficient relief with a smaller dose, whereas an opioid-naive obese person with obstructive sleep apnea (OSA) could experience respiratory depression with a larger dose.

Dr. Patanwala recommended a non–weight-based titration strategy in the ED. “Start everyone at a standard dose, such as intravenous morphine 4 mg, and then titrate them in a timely manner. Titrate based on patient request, not pain scores alone.” However, he urged caution with elderly patients and patients with OSA or pulmonary disease. “This method may not apply to these patients because they were excluded from the study,” he said.

Dr. Patanwala discussed the challenge of identifying drug-seeking behavior in the ED. “You can make your best guess, but the bottom line is that there is no guarantee that someone is or isn’t drug seeking,” he said. “You have to rely on what they say. It’s a difficult situation.” Drug-seeking behaviors can include reporting a pain score of 10 out of 10 and complaints of back pain and headache, but looking for any one of these behaviors does not reliably identify a drug-seeking patient because these behaviors also are extremely common among non–drug-seeking patients in the ED.

At his institution, Dr. Patanwala and his colleagues use a state database of controlled drug prescriptions to help determine whether a patient may be “doctor shopping.” They also use the database to verify medication dosages for ED patients because patients often don’t remember the correct dosages.

The same strategy of giving lower doses of propofol for sedation to elderly patients in the operating room also holds true in the ED, according to recent research by Dr. Patanwala and his colleagues. Their retrospective study found that patients aged 65 years and older required significantly less propofol for induction of sedation than patients aged 18 to 40. They also required significantly less propofol for the entire procedure than all of the other age groups (P<0.001). Mean induction doses were 1.4, 1 and 0.9 mg/kg and total doses were 2, 1.7 and 1.2 mg/kg for patients aged 18 to 40, 41 to 64 and 65 and older, respectively (J Emerg Med 2013;44:823-828).

Pharmacists can play an important role in optimizing pain management in the ED, considering these issues. A study conducted by Dr. Patanwala and his colleagues, but not yet published shows a reduction in time for the administration of analgesia and sedation in trauma patients when a pharmacist is present. “There is a role for pharmacists on many levels in terms of quality and bedside care in the ED,” he said. “The more the pharmacist is at the bedside and involved in decisions, the more likely patients with severe pain are to receive analgesics in a timely manner.”

—Susan Birk


Drs. Patanwala and Acquisto reported no relevant financial conflicts of interest.