At Emergency Physicians Monthly is a listing of the top 10 Practice Changing Abstracts from the most recent Society for Academic Emergency Medicine’s Annual Meeting. The last one is the one that most got my attention. Go read all of them, they are abstracts, so not much time is needed, but here is that abstract that I want to address –
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Elderly Emergency Department Patients With Pain Are Less Likely to Receive Pain Medication: Results From a National Survey 1999–2008
Platts-Mills et al [Abstract #395]
What were they looking for?
To determine whether elderly patients presenting with pain were less likely than younger patients to receive any analgesic medication or an opioid.
Emergency physicians probably dread the results of these studies about as much as paramedics dread the results of intubation studies. The good news is rare, but the results are important to look at for one very big reason.
No matter how much we deny that there is a problem, the problem does not go away.
The problem does get better, but the problem does not go away.
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Methods
Cross-sectional national survey data on ED visits over 10 years (1999–2008) collected by National Hospital Ambulatory Medical Care Survey.
Results
Patients age 75 or older with a pain-related visit were less likely to receive any analgesic (49%, 95% CI 48%-50%) than patients 18–44 (66%, 95% CI 65%-66%), 45–64 (63%, 95% CI 63%-64%), or 65–74 (55%, 95% CI 53%-56%). The same pattern of oligo-analgesia was seen for opioid medication. No analgesic medication was given to 48% of patients 75 or older with moderate pain vs. 32% of patients 18–44 and 30% of patients 75 or older with severe pain vs. 23% of patients 18–44.
This is not even limited to opioids. There are big differences when the choice is any medication.
Any analgesic – ASA (aspirin), APAP (acetaminophen), ibuprofen, celecoxib, et cetera. They do not specify what was included, but it is reasonable to include these medications in the category of any analgesic.
20 years ago, these figures might have been inverted. Rather than 70% of those over 74 years old receiving opioids for severe pain, we might be looking at 70% not receiving opioids for severe pain.
If we look at a graph of this, we can present this in several different ways. The four different age groups with the total 0% to 100% range. There is nothing on the side to take some of the width out of the bars, therefore the differences appear shorter.
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Change the information included in the graph to just show from 40% to 70% and all of the totals are still included, but the differences appear to be greater, because the differences are a greater portion of what is displayed. The same results are displayed, but the bottom of the graph is 40% and the top of the graph is 70%.
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The graph of the differences with opioid medication is similar. The data were only broken down into the 18 to 44 year old group and the over 74 year old group. Omitting the age groups in between can make the differences seem more dramatic.
The abstract presented the numbers for those who did not receive opioids, which is another way to magnify the differences, since most patients with moderate or severe pain did receive opioids. I converted all of the numbers to patients who did receive opioids, so that they would be consistent with the graphs for any analgesic.
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We can also cut out some of the chart to further enhance these differences. The graph below only shows from 40% to 80%.
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Why this could change your practice
Don’t forget to medicate elderly patients with analgesics and opioids when they are in pain. This is a nice study showing that elderly adults who present to the ED with pain are less likely to receive pain medication than younger patients, even after controlling for pain severity, sex, and race.
It would be nice to have all of the relevant data, but only the abstract has been printed, so far.
How many of the patients in these groups declined medication?
How many had contraindications, relative contraindications, absolute contraindications, imaginary contraindications?
How many of these patients had their pain resolved, or dramatically decreased, without the need for pain medication?
What were the differences in pain scores? What were the changes in pain scores?
The over 74 year old patients were less likely to receive any pain medicine and less likely to receive opioid pain medicine. But were the elderly patients, who did receive pain medicine, receiving as much relief from the pain medicine they did receive?
For example, for the 18 to 44 year old group with 7/10 pain, was their pain being reduced to 3/10 with opioid medication, while the over 74 year old group with the same 7/10 pain may only have their pain reduced to 5/10 with opioid medication?
What are the different end points used when treating patients over 74 years old as opposed to the end points used for patients between 18 and 44 years old?
There are many factors that might affect the differences in treatment, but this study appears to be just looking at the differences in the medications received according to age groups.
EMS-wise, I prefer to use fentanyl, because it will wear off much more quickly than morphine and I expect the pain management to be continued in the ED (Emergency Department).
This study suggests that my patients might be better off if I adjust my approach. My initial doses for elderly patients could be with morphine, which will last much longer, while some of the repeat doses should still be with fentanyl for the bumpy truck ride to the hospital. In this way, the fentanyl is wearing off en route, so that the patient should be safe without direct observation in the ED and the initial dose(s) of morphine will last much longer for those patients who might not receive further opioid medication in the ED.
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Go read the rest of the Practice Changing Abstracts.
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The graphs are created with NCES Create A Graph.
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Requesting orders for 82 y.o patient with abdominal pain.
Doc:” give 25 mcg of fentanyl for pain control and call back prior giving any additional dosing”
Man what am I medicating a cat?
did I mention this is a 150kg patient doc?
Chris,
Lions and tigers and LOL Cats – Oh, my!
While I generally start with 25 mcg fentanyl for the geriatric patients (those noticeably older than me), this paper/abstract only addresses whether any opioid was given, not whether the dose was appropriate.
As you point out in mentioning the patient’s weight, the information needed to determine if a dose is appropriate extends far beyond just the patient’s age, although some medical command doctors do not appear to understand that. They act as if there is some evil maximum dose, beyond which no medic shall go.
I have had one doctor tell me that it is never appropriate to give more than 6 mg morphine to a patient (awake and alert and breathing at a normal rate, but pain-free) after finding out that I gave 10 mg morphine (in addition to 400 mcg doses of NTG every 5 minutes, for a total of 6 doses – and 4 – 82.25 mg baby ASA). Pain-free and without side effects, when the patient had been experiencing severe chest pain a half hour earlier, when I first made his acquaintance. Then he tried to get me punished for exceeding his double secret maximum dose, even though his orders never mentioned any maximum. Some people just do not understand patient care.
As with the idea of insisting on demonstrations of competence with intubation – It isn’t about the patient – It is all about the ego.
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I too have great success with low dose fentanyl for abdominal pain in the elderly. I was just making a statement to get something going. I too have run into this situation you state about some secret maximum dose. Goes back you one of your quotes “2mg morphine = pain”
I hate when in the back of my mind I am wondering if I did my patient a FAVOR or a disservice by bringing them to the hospital.
I sometimes wonder if the ED is afraid of acute pain management.
Correction, that was an end of shift mistake.
****I sometimes wonder if the ED is afraid of CHRONIC pain management?