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Reflections on ED analgesia 81
but when we are treating a phenomenon like pain, that is so subject dependent,
how can we ignore the repeated subjective observations of the patients to
whom we are trying to give pain relief?
Another tremendous problem in the satisfactory management of analgesia
is the pain-pill dependency of many patients with and without chronic pain
syndromes. We become jaded in our response to patients with true pain, and
often do not believe the patient’s complaints, especially when the history
includes IV drug abuse. Yet what population is more likely to have a true
medical problem, often caused by the abuse? When such a patient presents
to your ED with cellulitis, is the pain complaint likely to be acted upon in the
absence of significant fluctuance and sufficient localization to be perceived as
an abscess? One of the presenting characteristics of epidural abscess is pain
out of proportion to physical findings. Relative neglect of the pain in a IV
drug-abusing patient may contribute to the often-delayed diagnosis of IV
drug abuse-related problems such as epidural abscess. In fact, the pain relief
usually provided such patients can only be described as oligoanalgesic.
Whether the habitual use is from IV drug abuse or chronic pain-pill use,
the patient who is not opioid naïve is often given smaller doses of pain
medication owing to fears of contributing to addiction. The probability,
however, is that the chronic user’s analgesic requirement is greater, not
lesser. We recommend not trying to figure out the patient’s underlying opioid
dosage. Instead, give the standard dosage for the condition and be prepared
to supplement dosing if the patient does not obtain relief. The oligoanalgesia
problem is also manifest in the patient who has a known dependency and
who is being discharged. To such a patient, we often mistakenly give either
too many, or too few, pills. This is a situation in which we most need good
coordination with a following primary care or pain management physician.
Unfortunately, these are the patients who have the least access to such kinds
of follow-up.
We may fear to contribute to addiction in a patient with an incurable
problem, such as metastatic cancer. It is wise to remember the three missions
of medicine: (1) to cure disease, (2) to relieve ongoing ravages of disease, and
(3) to provide comfort. When, in cancer, we can no longer have any hope of
curing the tumor, and we cannot relieve the ravages via surgery, radiation, or