How to manage pain in the ER: Ask the patient

Simply asking the question, "Do you want more pain medication?" resulted in satisfactory pain control in 99 percent of emergency department patients participating in a study. The study of a new evidence-based protocol to treat acute, severe pain in emergency department patients was published online yesterday in Annals of Emergency Medicine.

"The crowded conditions in most emergency departments in the U.S. are not conducive to fully individualized pain treatment," said Andrew Chang, MD, MS of the Department of Emergency Medicine at Montefiore Medical Center in Bronx, N.Y. "Our simple and easy to remember '1 + 1 + 1 + 1' protocol holds promise for safely providing adequate pain relief to patients with acute severe pain."

Researchers provided 1 milligram of intravenous (IV) hydromorphone to adult patients reporting acute, severe pain. Thirty minutes later, the patient was asked, "Do you want more pain medication?" The patient was then asked the same question at 30-minute intervals and given an additional 1 milligram IV hydromorphone each time he/she answered "yes."

Of the 207 patients enrolled in the study, 114 received 1 milligram of hydromorphone (the initial dose), 78 received 2 milligrams, nine received 3 milligrams and six received 4 milligrams. All but two of the patients achieved satisfactory pain control within 2 to 4 hours (the study period's duration). Almost all of the patients were satisfied with their pain treatment: 67 percent reported being very satisfied and 29 percent reported being satisfied.

"Pain perception is highly subjective and not necessarily correlated to pain scores," said Dr. Chang. "Our pain protocol is a departure from the more traditional ways of assessing pain relief, which typically use the visual analog scale or the numerical rating scale. Instead, our use of a non-numerical, simple yes/no question offers patients the ability to decide for themselves whether their pain is adequately controlled and allows them to balance pain relief against medication side effects such as nausea and drowsiness. This likely explains the wide range of pain scores (as much as 0 to ten) for patients who did not ask for pain medication."