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More than 60% of patients registering in EDs have pain as their primary symptom.1 Whereas up to 40% of those patients may have chronic pain underlying their complaint, close to 45% of all emergency patients are suffering from acute pain.2 Recognition of our collective failure as a specialty to adequately assess and manage pain started in 1989 with Wilson and Pendleton’s seminal article defining ED oligoanalgesia.3 All patients are at risk for oligoanalgesia, but certain subgroups—ethnic minorities, the aged, the very young, and those with diminished cognitive function—are more at risk for inadequate pain control4 (Table 38-1). The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) has mandated standardized assessments of pain in the ED, although some have questioned their validity.5 Other guidelines have been published by the Agency for Health Care Policy and Research.6 These documents serve as useful starting points but should be supplemented with more detailed and current information as appropriate.

Table 38-1 Barriers to Adequate ED Pain Control

Specific measures need to be taken to address pain and suffering in addition to treatment of the underlying illness or injury. It is not possible to generalize the extent and quality of pain control needed for a specific patient. For example, pain is an indicator of ongoing cardiac ischemia; the goal should be to eliminate all pain. An injured patient, on the other hand, may choose to endure more pain out of personal or cultural beliefs. Physicians may limit analgesics in those with head injuries to perform serial neurologic examinations. Whenever possible, medications that act on specific sites that initiate the pain signal are preferred, rather than agents such as opioids that mask pain. Migraine treatment is an excellent example. Preferred treatment includes a serotonin agonist (triptan) or a dopamine antagonist (phenothiazine) rather than the traditional use of the opiate meperidine—itself a weak serotoninergic agonist. This chapter reviews pain physiology, pain assessment, and management and provides a summary of analgesics useful for specific clinical settings.

Pain is the physiologic response to a noxious stimulus, whereas suffering—the expression of pain—is modified by the complex interaction of cognitive, behavioral, and sociocultural dimensions. Individual pain experience is therefore not static, but varies, depending on current and past medical history, physical and emotional maturity, cognitive state, meaning of pain, family attitudes, ...

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