Some trauma patients don't receive adequate pain relief

The question is why

Pain management is a critical part of trauma care. Untreated or inadequately treated pain intensifies the effect of trauma on respiration, hemodynamic stability, and renal and gastrointestinal function, leading to an increase in complications and deaths. It can also cause disabling chronic pain syndromes — the result of changes in the nervous system in response to repeated stimuli.

Although research has clearly shown that prompt and effective pain treatment improves outcomes, a surprising number of trauma patients don't receive it. In one study, up to 15 percent of patients received no pain medication in the trauma bay, and the mean time to administration after arrival stretched to well over an hour.

Meanwhile, a landmark seven-year study published last year in the Annals of Emergency Medicine found that older emergency room patients were far less likely to be given pain medication than younger patients were, even when pain levels were the same. When reporting severe pain, adults older than 75 were still 12 percent less likely to receive pain-relieving drugs than were middle-aged patients with similar symptoms.

Other research has found a wide disparity between what practitioners consider adequate pain relief and what patients do. In a prospective cohort study of 450 patients, two-thirds reported moderate or severe pain at discharge from the emergency department.

Yet it's possible that these studies, while focusing on some aspects of pain management, ignore others.

Michael J. Laughlin Jr., M.D., with the Department of Emergency Medicine at Mayo Clinic in Rochester, Minn., says that many factors come into play in managing trauma pain, including differences in pain perception and medication acceptance among patients and varying pain management strategies among practitioners.

"It's complicated," he says. "If a trauma patient doesn't complain or isn't able to describe the level of pain experienced, then the amount and frequency of pain medication are entirely provider dependent, and different providers are likely to do different things based on their own practice and experience."

But if practitioners sometimes under- or overestimate pain, so do patients. Dr. Laughlin notes that older adults are less likely to complain and less likely to request or accept medication than younger patients are.

"Older people tend to be more stoic," he says. "They've also lived longer and experienced more, so there is more opportunity for comparison. A woman who has given birth to several children may experience a certain degree of pain and consider it minor compared to the pain of childbirth, whereas someone who doesn't have children may find the same pain quite severe. One person's 2 on the pain scale is another person's 10, so you can never know what that severity truly is."

Opiophobia

Other factors that can complicate pain control include concerns about respiratory depression, hemodynamic instability, and side effects or drug interactions, especially in older patients.

Another problem is a bias against opioids. For many patients with intense pain, opioids are the only drugs that provide relief.

Dr. Laughlin says, "Most of the time, we're using narcotics — most often morphine, but there's a trend toward fentanyl because it works faster and has less effect on hemodynamic stability."

Even so, practitioners who aren't comfortable with opioids may opt for less-effective analgesics they feel are safer.

Acknowledging patient preferences

It's well established that good pain control:

  • Reduces pulmonary and cardiac complications
  • Lowers the incidence of deep vein thrombosis and pulmonary embolism
  • Aids recovery
  • Relieves physical suffering

So it stands to reason — and has been passionately argued — that traumatic pain should be aggressively treated. But Dr. Laughlin says it's not that simple.

He explains there is a constant play between the subjective perceptions and beliefs of the person in pain and the person treating the pain.

"I want to stress that we try to treat everybody's pain. But a lot of factors affect how that treatment is accomplished. Some people beg for pain medications; others are stoic. And some pain you just never control. It's tough to try to treat everyone's pain." He adds, "I've come to have the view that I'm not going to force patients to take something they don't want. It's one thing if they lose the ability to say no. But I respect people's opinion about what they want to put in their bodies unless it's utterly necessary to help them."