This introduction discusses the nuances of becoming comfortable with treating pain, general principles of pain assessment, and pain management. The book provides the clinician with practical information on pain management that can be used while working. The Joint Commission on the Accreditation of Healthcare Organizations has mandated documentation of pain levels for eating disorder (ED) patients. If an ED has prolonged waiting times or excessive delays, protocols that allow pain management prior to physician assessment should be considered for patients with such diagnoses. Other indications for advanced pain management directives could include obvious fractures, burns or amputations. While initiation of analgesics is improving, we need to improve our rate of recurrent analgesic provision. We can see that pain management is like any aspect of medicine: physician knowledge, physician experience, and patient expectation must all be combined to ensure optimal care.

Pain assessment plays an integral role in the ongoing efforts to improve overall pain management in the acute care setting. This chapter overviews the pain assessment process and outlines some pain rating tools that have been useful in the acute care setting. Some form of explicit pain assessment is necessary, since studies in myriad patient populations have failed to identify consistently reliable surrogate markers for pain. Despite pitfalls in self-reported pain scores, it is important for the objective pain rating to come from the patient. In clinical practice, the most commonly used rating scale is the verbal numeric rating scale. The advantages of the verbal numeric rating scale include ease of administration and high agreement with the visual analog scales used in most clinical pain management studies in acute care. In older adults who are cognitively intact, numerical rating scales or simple verbal reports of pain categories are preferred.

This chapter overviews the importance of analgesia as an important endpoint in prehospital care. Analgesia's importance is magnified by the frequency with which EMS providers interact with injured patients in significant pain. The chapter focuses on prehospital medication administration, with the understanding that not all medications will be available in all EMS systems. The perceived problem with out-of-hospital analgesia administration is that the drugs incur risk of hemodynamic or respiratory compromise. Examination-related issues other than the neurological evaluation are also prominent reasons for physicians not to administer prehospital analgesia. The opioids are the primary analgesic approach available to most EMS services. The prototypical opioid for use in prehospital care is morphine, which is demonstrated to be useful for a variety of adult and pediatric conditions encountered in EMS. Regional nerve blocks with local anesthetic injection are efficacious for field use in settings where physician prehospital providers are available.

This chapter considers the healthcare resource of pain treatment, with focus on findings relevant to acute care analgesia provision. It discusses the evolution of emergency department (ED) analgesia provision over time and overviews the clinically relevant lessons of research into disparities in pain medication administration. The treatment of pain in older adults can be impacted by age bias. Analgesia provision in geriatric patients is also affected by myriad issues relating to drug interactions and side effects. Two retrospective studies suggest that women receive significantly more analgesics than men. However, the preponderance of evidence argues against gender-related pain treatment. In contrast to the situations with race, ethnicity, and age, it appears that gender is not a major determinant of analgesia administration. Evidence of long waiting times to treatment, suboptimal pain relief, and high levels of pain on discharge indicate that we are only beginning to address oligoanalgesia in the ED.

Analgesia care in geriatric patients requires consideration of several age specific aspects of pain assessment and treatment. Geriatric oligoanalgesia is well known to occur in the acute care setting, and the problem has serious ramifications. Aging changes the physiology of drug absorption, distribution, metabolism, and elimination. Age-associated physiologic changes vary from patient to patient, in both degree and directionality. Opioid therapy provides an illustrative example of how altered elderly pharmacology dictates a conservative approach to analgesia titration. The Beers criteria have been adopted by many healthcare authorities, including the Centers for Medicare and Medicaid Services, and are now the most often-used consensus criteria guiding medication use in older adults. NSAIDs are widely prescribed, and frequently efficacious, in the acute care setting. Opioid selections for moderate (e.g. hydrocodone) or severe (e.g. morphine) pain in the elderly are generally similar to those for younger adults.

The approach to the patient with chronic pain should indeed be different to that for a patient with acute pain. Patients with chronic pain conditions tend to take analgesics for far longer than the few days or weeks that suffice for acute pain. Opioids and NSAIDs are often ineffective or contraindicated for chronic pain conditions. Effective analgesia in chronic pain may be gained by the use of antidepressants or anticonvulsants in patients who lack depressive symptoms or seizures. There are many forms of pain contract, but the common element to all is an agreement on a plan for managing chronic pain. One of the most important components of a pain contract is the patient's pledge to safekeep their medicines. Clinicians should be aware that sometimes patients with legitimate pain are relegated to drug-seeking behavior in order to achieve the pain relief to which they are entitled.

The NSAIDs and opioids figure prominently in the daily practice of EM. The gastrointestinal risks of NSAIDs are reduced by co-administration of gastroprotective therapy such as misoprostol or, preferably, proton pump inhibitors. The combination of NSAIDs and opioids fails to accrue additive (or synergistic) analgesic results. NSAIDs (and acetaminophen) will always claim one advantage over opioids: antipyresis. For most patients, the potential problems with opioids have little to do with efficacy in relieving pain. For short-term use as prescribed from the ED, the analgesic benefits of the opioids will counterbalance the risks foremost pregnant patients with pain uncontrollable by other means. Since most opioids are excreted to some degree in breast milk, opioids are best avoided in breastfeeding mothers. The controversy surrounding meperidine (pethidine) use in the ED is hard for acute care providers to avoid.

This chapter focuses on the general approach to non-standard routes for analgesia delivery. These may be rectal, nasal, nebulized/inhaled, transmucosal, and transdermal. Analgesia administration by the IN route has been most successfully described in the treatment of migraine headaches using sumatriptan. Morphine, fentanyl, and sufentanil are effective for IN administration. For myriad painful conditions, ranging from sickle cell crisis to cancer and even undifferentiated abdominal pain, nebulization of opioids such as morphine or fentanyl is shown to be safe and effective. Nebulized naloxone has been described for the reversal of opioid toxicity. The oral transmucosal route (OTM) administration of fentanyl is perhaps the best described alternative dosing strategies. The transdermal route (TD) administration of buprenorphine and fentanyl has been well described, but the onset of action is too prolonged for routine use of this approach in ED therapy of acute pain.

This chapter provides some insights into the book's recommendations for safe and effective practice of pain management in day-to-day emergency department (ED) practice. Pain is a cultural phenomenon as well as a physical one. Certain kinds of patients obtain more attention from their relatives or immediate companions and friends, and seem always to overreact to pain. There appear to be many patients (e.g. some with sickle cell crisis) who prefer meperidine to morphine for pain relief. It is wise to remember the three missions of medicine:to cure disease, to relieve ongoing ravages of disease, and to provide comfort. As an overarching guide, remember that because pain is subjective to the patient, it is also subjective to the physician. We have the training, the experience, and the expertise to interact in a way that provides comfort. It never hurts to lean to the side of providing that comfort.

Abdominal aortic aneurysm (AAA) pain should be considered by the acute care provider as a harbinger of aortic leakage or rupture. Therefore, analgesic selection in AAA is influenced by the high potential for hemodynamic instability. This chapter discusses the role of opioids and NSAIDs in abdominal aortic aneurysm. When treating pain in patients with suspected ruptured AAA, the most important consideration is the effect the analgesic will have on the patient's hemodynamic status. Opioids, in small titrated doses, are the analgesics recommended by experts in AAA pain relief. Most opioids can cause minor reductions in heart rate and blood pressure. Hypotension is much less likely to occur with fentanyl since this agent does not cause histamine release often associated with morphine. In patients with normal renal function, NSAIDs (e.g. ketorolac) have been used perioperatively, without sequelae, in patients undergoing abdominal and retroperitoneal procedures.