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Close to 80% of patients evaluated in emergency departments complain of pain, and one of the biggest challenges facing health care providers is how to objectively treat a symptom that is inherently subjective. 1 All patients deserve to have their pain managed, but inadequate treatment of pain remains a major problem – as does abuse of pain medications. The truth is that not all pain is treated equally. 2,3
Many studies have found that race and gender affect the way pain is assessed and treated. Age is another factor, according to a 2014 article published in the journal Pain. 1 “Across all settings, whether it be a doctor’s office or an emergency room, acute pain is treated differently. Women and minorities get less analgesics and opiates. In our study we found that age also changes the way acute pain is treated,” says Ula Hwang, MD, associate professor of emergency medicine at the Icahn School of Medicine at Mount Sinai in New York City, and lead author of the study.
Age and Acute Pain
The Pain study was a retrospective review of acute pain treatment in five emergency rooms involving close to 7,000 patients. The authors chose to evaluate abdominal pain and fracture pain – the two most common acute pain conditions in older adults. 1 “Patients over age 65 reported lower pain scores and were less likely to be treated with an analgesic or an opioid compared to younger patients,” Hwang said.
The study found that older (at least 65 years old) and oldest (at least 85 years old) patients had lower initial and final pain scores despite getting less overall treatment. The study also found that type of pain made a difference. Older patients were more likely to be treated for fracture pain than abdominal pain. Part of the problem is that older patients may believe that pain is a normal part of aging. 1 “The key takeaway is that pain is undertreated in the elderly. You need to address and treat the condition, but don’t forget to treat the pain,” Hwang said.
“There was a saying in medical school that the organs of the aged suffer in silence,” according to Mary I. O’Connor, MD, professor of orthopedic surgery at the Mayo Clinic in Jacksonville, Florida. “Many doctors are wary of side effects like constipation, confusion, and cognitive impairment when using opioids in the elderly. But you still must find a way to manage pain to improve outcomes.”
Gender, Ethnicity, and Acute Pain
In 2011, O’Connor participated in a breakout session on gender and ethnic disparities in pain management. Coverage of the session was published in the journal Clinical Orthopaedics and Related Research. The article concluded that there were real challenges, both biochemical and socioeconomic, that needed to be addressed through education and research.4 “Those challenges still remain. We still need to learn how to assess differences in race, gender, and age when treating pain. We need more treatment options, and we need a more holistic approach to pain management,” O’Connor said.
Many pain syndromes are more common in women, including fibromyalgia and tension headaches. Women may be more likely to have greater pain after surgery. Hormonal factors may play a role. Pain may even be inversely proportional to estrogen levels.4 “There are clearly differences in the way women and men experience pain, not just emotional differences, but real biologic differences,” O’Connor said.
Studies have demonstrated a lower threshold of pain for African Americans and Asians. The neurobiology of pain in different racial groups is poorly understood. Prescriber bias against minorities, both overt and unconscious, also exists and must be addressed. Providers may fear that minorities have a higher risk for opioid abuse. Minorities may also have a higher rate of fear surrounding medical care, which can complicate pain assessment.
Better Acute Pain Assessment
In the 1990s, the American Pain Society began to call pain the “fifth vital sign” in an attempt to combat inadequate pain management. A patient’s self report of pain was stressed as the single most reliable indicator of pain.3 “The pendulum has swung too far toward basing pain treatment solely on pain rating scales. The unintended consequence is overuse of opioids. We have put our patients at risk and done them a disservice,” O’Connor said.
A recent review of acute pain assessment by the Agency for Healthcare Research and Quality emphasizes that all patients deserve a complete pain workup, including a complete history and physical, and careful documentation of pain location, intensity, and quality. Simply using a numerical pain score is insufficient. Pain perception must be seen as multifactorial. 2
Best Practices for Acute Pain
The American Academy of Emergency Medicine has issued treatment guidelines for managing noncancer pain in the emergency room. The guidelines include limiting opioid prescriptions to seven days, avoiding long-acting opioids, and not prescribing opioids for conditions like back pain and dental pain. They also note that prescription opioids now cause more deaths than heroin and cocaine combined.5
“Best practice for acute pain is to manage it in a way that improves outcomes. Use a multimodal approach. If opioids are needed, use them for short periods and combine them with nonopioid analgesics. If acute pain continues beyond three to four weeks despite best efforts, you should consider referring the patient to a chronic pain specialist where a multimodal team approach can be instituted,” O’Connor said.
Multimodal treatment may include combinations of opioid and nonopioid analgesics as well as coanalgesics and nonpharmacologic treatments. Coanalgesics may include local anesthetics, muscle relaxants, and anticonvulsants. Nonpharmacologic treatments may include deep breathing, hot and cold compresses, biofeedback, acupuncture, massage, and guided meditation.6
Acute pain, by its nature, requires a careful approach. It starts with the understanding that people of different genders, ages, races, and dispositions experience pain differently. More research and education are needed to improve care. For now, the best practice is a multidimensional approach to assessment and a multimodal plan for treatment.
“We don’t want the pendulum to swing back to undertreatment of pain. If you screen and treat appropriately, you should not need to undertreat. Don’t lose sight of the fact that all pain is not the same. Some people are highly functional with pain, and some are not. When duration and impact of pain become a quality of life issue, it is time for a chronic pain referral,” Hwang said.
Chris Iliades, MD, is a full-time freelance writer based in Cape Cod, Massachusetts.
This article was medically reviewed by: Pat F. Bass III, MD, MS, MPH.
References
1. Hwang U. Belland LK, Handel, DA, et al. Pain. 2014, doi:10.1016/j.pain.2014.09.017.
2. Agency for Healthcare Research and Quality, Acute pain assessment and opioid prescribing protocol.
3. American Pain Society, Assessment of Pain.
5. American Academy of Emergency Medicine, Model Emergency Department Pain Treatment Guidelines.
6. Medscape, Acute Pain: Assessment and Treatment..
