Algia

Almost every ER patient complains of some type of pain. Cephalgia, neuralgia, arthralgia refer to head, nerve and joint pain respectively. The root algia is from Latin. Angina from the Latin for choking also is used for several painful conditions. Angina pectoris is the term for pain in the chest from narrowing or blockages of the coronary arteries. Intestinal angina is used to describe pain from narrowing or blockages in the arteries that supply the GI tract. Ludwig's angina is severe throat pain from an infection in the mouth or throat that spreads towards the chest through the fascial plains of the neck. Colic is another medical term for pain that were thought to occur from intestinal sources. It's three types are infant (general crankiness without another source), renal (from the passage of a kidney stone) and biliary (from gall stones or bile sludge).

Pain is a protective mechanism. If one touches something hot, a reflex arc in the central nervous system causes withdrawal from the source of the heat even before we become fully aware of the pain. Noniceptors in the peripheral nervous system respond to heat, cold, pressure and sharp stimuli. These pain signals are carried to the brain by tracts in the spinal cord. The brain processes the information that one consciously perceives as pain.

Pain from an injury is from an obvious source and will resolve as the injury heals. A broken ankle will cause severe pain. Elevating and immobilizing the injured part with give some relief. As the fracture heals the pain will lessen and eventually resolve with complete healing. Similarly pain from an intrabdominal infection or from colic will resolve after appropriate treatment.

Treating acute pain is an important part of ER care. Unfortunately many physicians under treat acute pain. I have become much more "generous" in treating acute pain after my experiences as a patient with four major abdominal surgeries. PCA or patient controlled analgesia gives the pain sufferer, usually post-operative, the means to obtain IV pain meds by pushing a button. The amount and time interval between doses are set and locked. My only use of PCA was a failure. When I told the anesthesiologist (PCA may also be ordered by the surgeon) that the dose was too low and that I was getting little if any relief, he assured me that the dose was adequate.

Conscious sedation is used in the ER for patient comfort during painful procedures such as reducing fractures or dislocations, incising and draining an abscess or for a lumbar puncture. The drugs used for this sedation may include short acting pain medications such as fentanyl. A short acting benzodiazepine sedative such as midazolam is often combined with fentanyl to provide sedation with pain control. I prefer propofol. This drug causes a dissociation between the painful procedure and the perception of the pain. It's short duration and lack of long term side effects make it a valuable asset for the ER doc.

There are three main types of pain medications. NSAID's include ibuprofen, naprosyn, ketorolac and others. Acetaminophen is also a mild analgesic that may be taken solely or combined with an opiate. NSAID's are very effective for most mild to moderate short term painful conditions. Toothaches, menstrual cramps, minor orthopedic injuries and most headaches respond well to NSAID's. Moderate to severe pain usually require the third class of pain meds, opiates.

Opiates work by binding to the mu receptors in the nervous system. These receptors are widespread and are the target for our intrinsically made pain suppressors, endorphins. Anyone who has hit the "runner's high" during a prolonged workout has felt the effects of endorphins. The placebo effect is relief from the pain and other symptoms of disease or injury by an inert "sugar" pill. The belief that one is receiving treatment may cause the release of endorphins and explain the placebo effect.

Heroin, opium, morphine, codeine, hydromorphone, methadone, hydrocodone and oxycodone are all derived from the alkaloids obtained from the opium poppy. Other medications in the opiate group include meperidine, propoxyphene and fentanyl. Pills, liquids, patches, suppositories and injections are all ways of introducing these medications into the body. When given in adequate amounts for a limited time, opiates are both effective and safe.

The problems arise with pain that is never ending and psychological issues that effect pain perception. Neuralgia or nerve pain can last a lifetime and be debilitating. Damage to nerves from injury, infections (shingles), or metabolic diseases (diabetic neuropathy) may lead to constant pain. Pain from arthritis or disc disease may not resolve with treatment of the underlying condition. Phantom pain from amputated limbs is common and may be permanent. Pain from cancer is another example of the need for chronic pain management.


Patients with depression have an altered perception of pain. The flip side to this is that chronic pain may lead to depression. Antidepressants are often used with other medications to treat some forms of chronic pain. Anticonvulsants such as gabapentin have been used to treat neuropathic pain. Psychological counseling, physical therapy and exercise are also tools in the holistic approach to chronic pain management. It is important that patients with chronic pain be given long acting pain medications such as methadone, prolonged released morphine or fentanyl patches. A short acting medication such as hydrocodone or oxycodone should be available for acute exacerbations of the underlying chronic pain. The physician must take tolerance into account, and be willing to gradually increase the dose of the long acting medication as needed.

Physicians must accept some of the blame for the abuse of opiate pain medications by patients. Giving too little medication, for less time than is required for healing, will force the patient to try and find relief somewhere else. Some physicians give too strong an analgesic and this may lead to tolerance. Tolerance and addiction are the downside of opiate medications. There is evidence that the number of mu receptors increases in patients taking opiate medication for a prolonged period of time. The need for greater doses of pain meds to achieve the same level of relief (tolerance) may be the result of the increased number of mu receptors. The symptoms of withdrawal from opiates are all too real. The "screaming" of the mu receptors "feed me" is what makes withdrawal a living hell.

Drug seekers are the bane of an ER doc's existence. The causes of the pain may be genuine but their drug addiction makes them a drain on the time and patience of the ER staff. It is sometimes difficult to separate the patients with pain and the addicts looking to score. I have received letters, from various regulatory agencies, telling me that a patient who I prescribed opiate pain meds had received multiple prescriptions from multiple doctors. Multiple ER visits for minor problems, "allergies" to every drug except the one they want, and reported pain out of proportion to the injury, all may be indicative of the drug seeker. Threats to "call my lawyer" and verbal and physical assaults also are the signs of drug seeking behavior.

When I graduated from medical school in 1977, I didn't take the Hippocratic oath. My classmates and I took the Oath of Maimonides instead. "In the sufferer, let me see the human being."