201703-Jan-Andrew-Dr-Feb17 Emergency Physician Dr Andrew Jan says EDs can do better when it comes to pain management.

201703-Joondalup-ED7-Jan08Pain sends patients to Emergency Departments (EDs) and up to 75% who attend have pain. Current pain relief measures are predominantly pharmacological along with procedural and surgical interventions. However, our current approach to pain relief may have negative consequences.

Over the past two decades opioid prescribing has markedly increased. The director of the US Centre for Disease Control and Prevention, Tom Frieden, says of opioid prescribing: “We know of no other medication that’s routinely used for a non-fatal condition that kills patients so frequently.” In Australia, there were 806 oxycodone deaths 2001 to 2011 and this figure is rising.

EDs commonly use oxycodone as an analgesic although they only prescribe a small proportion of all oxycodone used in Australia. We do know though that opiates initiated in ED increase the risk of later misuse and addiction.

Are we helping or hurting patients with our current approach, given both the short and long-term side effects of pain medications? Maybe we can do better! Do we need other models of care in the ED and for pain medicine in general?

Prior to the medical (or Cartesian) model introduced in 16th century, pain management was dominated by various cultural and spiritual aspects. We now know tissue injury and pain does not have a one-to-one relationship – that there are emotional, cultural and spiritual dimensions for pain.

For example, the narrative medicine model highlights the humanistic psychology perspective. The humanists would see the pain experience as a ritualised initiation into some sort of mystery, that patients must on their own, ‘figure out’ and then move onto a new direction in their life. Pain may be regarded positively as an education or even a gift – as negotiating the path between pain and pleasure, happiness and despair is an inherent part of the human condition.

Is our medical model becoming a short-sighted assembly-line medicine for managing body parts? Should we consider therapies from other paradigms that have some evidence of efficacy and do less harm, while encouraging personal growth?

Even in the ED there are opportunities to introduce such alternative pain therapies for a patient’s pain crisis, as a stand-alone or as an adjunct to simple analgesia (while there will always be a place for standard analgesia, opioids and procedural interventions).

These therapies may include guided imagery, breathing and relaxation techniques, acupuncture, explanation, comfort positions, attentional techniques and cognitive behaviour interventions.

This more integrated approach offers a middle path where the ‘whole person’ is treated and their individual life story is foremost with the medical model assisting their journey. Further research into alternative pain therapies to investigate their efficacy and suitability in this setting is needed.

ED. References available on request from the author at drandrewjan@gmail.com

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