Do You Want More Pain Medication?

By Pat Anson, Editor

The question sounds so simple.

An emergency room doctor asks a patient in pain, “Do you want more pain medication?"

If the patient says “yes,” an intravenous injection of the opioid painkiller hydromorphone is given.

Thirty minutes later, the question is asked again. If the patient is still in pain, another injection is provided -- and another after that and another after that.

In all, up to four injections of hydromorphone are given within four hours if the patient asked for them.

That simple protocol – far different than what many chronic pain patients experience in a hospital emergency room -- resulted in satisfactory pain control in 99 percent of ER patients participating in a new study published in the Annals of Emergency Medicine.

Over 200 patients in acute pain were involved in the study, which was designed to individualize pain treatment at Montefiore Medical Center in the Bronx, NY, one of the busiest emergency rooms in country.

Almost all of the patients were satisfied with their pain treatment: 67 percent reported being very satisfied and 29 percent said they were satisfied. About half asked for just one injection. Only two patients asked for all four injections.

"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,” said lead author Andrew Chang, MD, of the Department of Emergency Medicine at Montefiore Medical Center.

“We initially had concerns that a protocol in which patients could receive as much as 4 mg hydromorphone simply by requesting it when asked might facilitate drug-seeking behavior. However, we found no evidence to support this concern.”

Patients in chronic pain or those who had used opioids in the past 7 days were excluded from the study because the research only focused on patients in acute, short-term pain.

Readers who posted comments to earlier stories we’ve done about emergency room pain care often express frustration with the treatment they received. Some were denied opioid analgesics. Even one doctor lamented the quality of ER pain care.

“I dread the day when I need to get ER help. Sadly, most of us physicians don't know it all. And, so far as pain care goes, it seems to have become medical care by committee. Caring for patients as individuals seems to have slipped their minds,” wrote Michael.

How have you been treated in emergency rooms?

Should chronic pain patients have been included in this study?