MORE than 80% of patients who present at emergency departments (EDs) with significant pain from common conditions do not receive effective pain relief within an hour, research shows, with experts divided over whether acupuncture may be part of the solution.

A study at four large tertiary hospitals in Melbourne compared the efficacy of pharmacotherapy, acupuncture and a combination of both among 1964 patients presenting at the ED with acute low back pain, migraine or ankle sprain and pain ratings of at least 4 on the 10-point verbal numerical rating scale.

Patients were randomised to receive either acupuncture alone, acupuncture plus pharmacotherapy or pharmacotherapy alone. Pharmacotherapy was given according to a standardised protocol, including a choice of first and second line drugs as well as rescue medication. Rescue therapy, including parenteral opiates, was provided to patients with inadequate pain relief after one hour, or earlier if the treating physician deemed it necessary.

Across the three arms, fewer than 40% of participants experienced a reduction in pain of two points or more at 1 hour after the intervention, and more than 80% of patients still had a pain rating above four.

Overall, only 16% of patients received “clinically relevant pain relief” at 1 hour – defined as a score less than 4.

However, patients reflected more positively on their pain relief in hindsight, with 80% of each group saying that they would probably or definitely repeat their treatment when surveyed 48 hours after the event.

The acupuncture-only group received significantly more rescue medication therapy than the pharmacotherapy groups (25% acupuncture v 15% combined v 15% pharmacotherapy at 1 hour; P = 0.016). Oral opiates were the most common rescue medication in the acupuncture group, whereas parenteral opiates were more commonly used in the pharmacotherapy groups.

Published in the MJA, the assessor-blind study concluded that acupuncture was equivalent and non-inferior to pharmacotherapy in providing analgesia for patients with back pain and ankle sprain, but that all of the therapies were suboptimal.

“Pain management in EDs in general must be improved,” the authors wrote. “The potential role of acupuncture should also be further explored, including determining the conditions in which it is most useful and the feasibility of employing it in emergency settings, including acupuncture training for emergency physicians and allied health personnel.”

However, the authors of acute pain management guidelines said that the MJA study’s findings about the equivalence of acupuncture should be treated cautiously, claiming that acupuncture was not compared with evidence-based care but usual therapy.

Professor Stephan Schug, who co-edited acute pain management guidelines for the Australian and New Zealand College of Anaesthetists and its Faculty of Pain Medicine, said that the study provided a “reflection of what’s actually happening in ED: suboptimal therapy for severe pain”.

“Although the authors of the study claimed that they were using the relevant guidelines for pharmacotherapy, I disagree,” he said. “Some of the drugs mentioned [are] not first line and others would be possibly preferable. Also, many of the doses used are too low for acute pain relief.”

For instance, paracetamol-dextropropoxyphene was one of the drugs used in the 2010–11 study, but guidelines have not recommended this for many years.

The doses of NSAIDs given were also far too low for treatment of acute pain. The study authors did not report on what drugs patients in the pharmacotherapy group actually received, only on the protocol for pain relief.

Professor Shug commented: “According to the protocol, they made patients wait an hour for morphine, when the average pain score was 8.5 … If I were in one of those patients’ situations, I would hope someone would give me fast onset pain relief medication”.

Professor Schug said that the implementation of guidelines was “always problematic”, but that in pain medicine in particular, hospitals may not be providing evidence-based care involving drugs of addiction because of concerns about drug-seeking patients.

“I don’t think it should be a first assumption that a person who walks into ED with a pain score of 8.5 is a drug-seeking patient,” he said. “It would be appropriate to see substantial use of tramadol, tapentadol and even conventional opioids, particularly oral opioids, as first line therapies in this setting.”

Professor Jane Trinca, who also co-authored the guidelines, told MJA InSight: “Pain is generally not well managed in busy EDs and would be helped by more expertise in this area with some dedicated use of acute and chronic pain specialists”.

She also suggested that the MJA authors overstated the potential benefits of acupuncture in the ED. “I would not prioritise this unless we could find a particular patient group or condition in which it was especially effective in the ED setting,” she said.

Study co-author Dr Michael Ben-Meir, director of the Cabrini Hospital’s ED, said that while the study did not test whether the pharmacotherapy provided was evidence-based, the analgesia decisions were made by physicians who would be competent in treating pain according to the guidelines.

“This study occurred at four major Australian EDs, with treatment at the discretion of treating emergency physicians whose knowledge of analgesia options and assessing pain is generally very good, and who were using drugs in a timely manner,” he said. “Many of these patients would have received paracetamol with codeine and or oxycodone, which is the first line gold standard for acute back pain.”

Dr Ben-Meir said that it was reasonable to conclude from the study that acupuncture was a “mild-to-moderate analgesic, equivalent to existing pharmacotherapy”.

He rejected the suggestion that pain management specialists could be placed in the ED, saying: “Emergency physicians are specialists in the management of acute pain, with 60% of emergency attendances presenting with pain as their main complaint”.

He added: “Our main need for pain management specialists is the management of complex chronic pain syndromes with acute exacerbations, which is a relatively small proportion of our ED cohort”.


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14 thoughts on “Pain management in emergency rooms “suboptimal”

  1. Sue Ieraci says:

    For people interested in further reading, here is an article with some fascinating historical and cultural insights about acupuncture, including a de-bunking of so-called “acupuncture anaesthesia”:

  2. Sue Ieraci says:

    It’s been a long time since junior doctors in EDs withheld analgesia for abdominal pain, awaiting review by a surgical registrar (and this was because the surgical registrars insisted that this could “mask” the signs). For many years, it has been known that this is not correct.

    Readers should not see this paper as representative of analgesic practices in EDs. Timely, effective analgesia has been a focus for some time. An audit of analgesia for major trauma, renal colic, AMI or fractures would be a better quality measure for overall analgesia practice.

  3. Sue Ieraci says:

    No amount of protestations about study methodology can compensate for the fact that acupuncture has no effect beyond placebo.

  4. Prof Pam Macintyre, DIrector Acute Pain Service Royal Adelaide Hospital says:

    Just a very quick comment on titration of opioids according to a patient’s pain scores alone. I agree with Rabid Dog on this. There are many reasons (and not just drug-seeking – that would be a minority of patients) why a patient may report high pain scores. Not all these patients will need an opioid or, more especially, more opioid. It is better to also look at the patient’s functional activity (Functional Activity Scores [FAS] can be used}.

    These are outlined in the Acute Pain Management: Scientific Evidence (APMSE) document already mentioned (potential conflict: I was lead editor for the 2nd and 3rd editions). There is also a paper listed in there by Vila et al (2005) which shows the dangers of chasing pain scores only – marked increase in the risk of respiratory depression. Pain scores should be used as only part of the assessment of a patient’s pain and aiming for scores of <4 in all patients may not be needed or safe. And not all pain will be opioid-responsive.

    See for one comedian's take on pain scores and why he says everyone should say '8'. 🙂

  5. Dr Ian Relf, Medical Acupuncturist Austin Hospital Melbourne. says:

    The Medical Acupuncture shortlist of problems with the trial:

    1. With great respect to the medical expertise listed, there was no fully qualified and experienced acupuncture performed in this trial. Sorry.
    I’m sure ED physicians would be outraged if anyone did an ED trial without using ED physicians.

    2. Considering pain examination is not understood or taught in terms of anatomical pain level / diagnosis / prognosis; the clinical pain diagnoses are likely to have been incorrect.

    3. Not sure why acute ankle sprains were included in the trial.

    4. Measuring 1 hour outcomes for all pain presentations with acupuncture is like expecting tumour size reduction (in 1 hr) for oncology admissions. Good luck with that.

  6. Bryan Walpole says:

    This study casts a wide net of accusations against emergency management of acute pain, but look at what they studied…
    LBP ( presumably non traumatic) nearly always present for hours or days befor ED presentation, and responds to reassurance (same as acupuncture) posture,, heat pack, gentle massage,adequate Paracetamol/ibuprofen, and within an hour most are more comfortable, and rarely need rescue medication.
    Coedine is not a useful drug in back pain. It can make matters worse.
    Sprained ankle 5/10 pain at the most, and helped markrdly with ice, splintage ( pending X Ray) and elevation, rarely needs more than the above level 1 analgesics.
    Migraine , I only had access to the abstract, but migraine is a nortoriously variable presentation, from Classcal with aura, vomiting photophobia, that responds best to triptans, to the “Bad headache” that accounts for about 50% of migraine claims, its usually present for hours/days before attending ED. In the olden days, most just wanted Pethdine.
    With reassuarnce, social matters attended, Level 1 analgesics, maybe a sedative, quiet room, in an hour many are asleep.
    These are poor cases indeed to start judging ED quality care.
    All are self limiting in most cases. Analgesia can be titrated, oral, and gradual.
    Try studying Renal stone, long bone fracture, SAH AMI, and see how promptly they are attended with analgesia..

  7. Ruth Armstrong says:

    This news story and the comments above provide a very useful response to the study published in the MJA.
    I agree with the above comments about potential biases and flaws in the study that are not addressed in the published paper.
    In addition, given this is a study with no long-term follow-up, a six year time lag to publication seems excessive, and is likely to have diminished the study’s relevance.
    Despite this, the study has been reported fairly uncritically in the media
    including the medical media
    There are always going to be problems like this with an ED-based, prospective RCT but it is unfortunate that this large NHMRC-funded study has taken so long to produce findings in which it is difficult to have confidence.

  8. randal williams says:

    As a young ED doctor I was taught not to give narcotic pain relief to patients with an acute abdomen until they had been seen by the surgical registrar or consultant, the rationale being that it would mask clinical signs. Later, as a surgeon myself, I quickly realised that it was not only humane to give such pain relief on arrival in the ED, but it actually made assessment easier, and did not mask abdominal tenderness or rigidity. Some of this may still be a hangover in some ED’s. These ideas die hard.

  9. Sue Ieraci says:

    Agree with both “Rabid” and Ed Brentnall (greetings, Ed!) – this is a study that showed that it is possible to deliver sub-optimal analgesia in various ways – both with needle-placebo and tablet- placebo.

    I don’t agree, whoever, that, in general, ED pain-relief is as inadequate as others are suggesting. This has been a focus for many years now, with nurse-initiated analgesia, titrated intravenous narcotics, intranasal narcotics, nitrous oxide, splinting and ice or heat, in addition to pre-hospital inhaled analgesics. More widespread use of ultrasound has also increased the effective use of nerve blocks – especially femoral. I see no “fear of opiates” where I work – on the contrary.

    Concomitant with the ED focus on improved analgesia is the community concern about use of oral opiates, and the measured increase in harm from opiate abuse. The two, unfortunately, go together. While EDs are often targeted for criticism here, we must also remember that post-operative use of narcotics is an important initiator for subsequent abuse. It’s not possible to have effective acute analgesia with a zero percent risk of subsequent abuse.

    Having said all that, we don’t need to adopt placebos in acute practice. We need effective, evidence-based pain relief, delivered as fast as is feasible, in patients who need it, and local measures like splinting, ice or heat for those who don’t.

    And finally, we also need to accept that some degree of pain is a part of recovery. Patients need a plan for analgesia at home, but don’t need to be completely pain-free in order to leave hospital.

  10. Scott Taylor says:

    Poorly designed study but I do believe that in general we are treating acute pain in our EDs suboptimally. This is multifactorial in nature, which include (but are not limited to):
    – inadequate education
    – time demands
    – fear of opioids in both medical and nursing staff (irrational fears of addiction and drug seeking, underdosing etc)
    – inadequate recognition of expected disease courses and potential complications from poorly treated pain
    – failure to utilise adjuncts, regional nerve blocks and multimodal analgesia
    – problems once patients are admitted to wards (hesitance and unfamiliarity with PCAs/infusions, documented arbitrary dose limits)

    Obviously we need to target several areas in order to improve performance.

  11. Dr Mick Vagg says:

    The publication of Acute Pain Management: The Scientific Evidence has been a major landmark in promoting evidence-based acute pain care. It can be downloaded free in pdf format and is regarded worldwide in the field as the premier resource to inform practice. It is an incredibly valuable publication which deserves respect. I don’t think we will see acupuncture making it into the next edition on the basis of this study, for the reasons articulated above by Rabid Dog, besides others that s/he didn’t mention. However, I don’t agree entirely with Rabid Dog’s dismissal of Profs Trinca and Schug just because they don’t work in rural EDs. They are involved in the Acute Pain Services of St Vincent’s in Melbourne and the Royal Perth Hospital respectively, so they regularly manage acute, severe pain and have done for years. Their credentials and experience actually do mean that their synthesis of over 7,000 references in APMSE is well worth adopting for the good of patients.

  12. Edward Brentnall says:

    I gave up the use of dextropropoxyphene before my retirement in 1994. I totally agree with “Rabid Dog”.
    Edward Brentnall

  13. Edward Brentnall says:

    I gave up the use of dextropropoxyphene, and took it out of my Departmental drug store, before I retired in 1994.
    I totally agree with “Rabid Dog”.
    Edward Brentnall

  14. Rabid Dog says:

    Where to begin with study?
    1. No sham acupuncture treatment;
    2. No outline of the pharmacotherapy option(s) available
    3. Use of dextropropoxyphene? Bah! Humbug! A rubbish drug, not used personally in 15 years, nor by most ED docs in the last 5-10
    4. RICE for ankle sprain! Can use for back pain too
    5. Most ankle sprains do not fit criteria for ‘severe pain’
    6. Ditto back pain (when truly from the back)
    7. “The acupuncture-only group received significantly more rescue medication therapy than the pharmacotherapy groups”
    8. “Oral opiates were the most common rescue medication in the acupuncture group, whereas parenteral opiates were more commonly used in the pharmacotherapy groups.” I should hope so! It’s not called a ‘hierarchy of analgesia’ without reason!
    9. “Professor Shug commented: “According to the protocol, they made patients wait an hour for morphine, when the average pain score was 8.5 … If I were in one of those patients’ situations, I would hope someone would give me fast onset pain relief medication”.” How many patients do we see in ED sitting up in bed playing with a telephone, or eating a bag of chips, claiming 8/10 pain?
    10. Pain is NOT a diagnosis – rather a symptom of underlying patholgy, the determination of which is the end point (and expertise) of ED docs.
    11. Guidelines exist for the GUIDANCE of the wise man, and the OBEYANCE of the foolish man….
    BTW – Professor Trinca and others that write such guidelines are welcome to come join me in rrual and remote EDs throughout Australia and provide provide assistance overnight. Anytime that suits them. What’s that/ They don’t eveer enter an ED, and have no idea where most of the remote towns in WA/Qld/NSW etc actually are?!!!

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