A prospective, non-interventional study of assessment and treatment adequacy of pain in the emergency department of a tertiary care cancer hospital
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0973-1075.121529
Source of Support: None, Conflict of Interest: None
Introduction: Pain is the most common reason for emergency department (ED) visits by the cancer patients. Treatment inconsistency and inadequacy are reported worldwide in the management of ED pain. We conducted a non-interventional observational study of 100 patients visiting ED with moderate to severe pain in a tertiary care cancer center.
Keywords: Cancer, Emergency department, Pain
Cancer pain occurs approximately from 30% to 50% of patients receiving active treatment for solid tumors and 60-90% of patients with an advanced disease.  Pain imposes suffering and negatively impacts the quality-of-life. Breakthrough pain often draws patients to the emergency department (ED), which merits a proper assessment. Various studies conducted world-wide has proven that pain is the most common reason for cancer patients to seek the ED services. , There is also evidence that these patients receive suboptimal pain management. ED pain management inconsistencies and inadequacies are prevalent across the globe. The scenario is worse in developing countries like India. Several barriers have been described in the optimum pain management in this setting such as lack of reporting, poor communication and misconceptions on the part of patient and the ED health care staff.  The purpose of this prospective observational study is to describe the characteristics of emergency cancer pain and its treatment by Oncologists. Treatment compliance of prescribed medication was also evaluated during this study.
Consequent to approval from Institutional Review Board, a prospective non-interventional study was conducted in the ED of a cancer hospital during April-June 2011. Being a pilot study, we included 100 adult cancer patients visiting ED with the complaint of pain. The research was registered retrospectively at Clinical Trial Registry-India (CTRI), registration number being CTRI/2011/08/001979 (Registered on: 30/08/2011).
Adult cancer patients visiting ED with a predominant complaint of pain.
The study was conducted in the ED twice a week by the investigator while he was on "24 h call duty." All the patients in this study were accrued during night hours, when acute pain service or pain clinic services were not available. The investigator received a call from the ED nurse if any patient with the complaint of pain reported to ED. Thus screened, 100 adult cancer patients were included in the study. The investigator was not involved in any treatment of these patients whatsoever. Pain management was provided by resident doctors who were working for their super-specialty degree in oncosurgery, medical oncology or radiation. Later, patients were interviewed by the investigator for pain related history, current analgesic treatment and its compliance. Details of the presenting pain severity, site, duration and nature were also noted. Severity of pain was assessed by using numerical rating scale (NRS) (0-10). No specific tools were used to define pathophysiology of pain, e.g., visceral/somatic/neuropathic pain etc., The nature of pain was determined clinically. The assessment of compliance was done in patients who had analgesics prescription advised by doctors involved in ambulatory cancer care. Compliance toward prescribed analgesics was graded as good (if patient is 100% adhered to prescribed regime), fair (patient is not taking analgesics in doses and frequencies prescribed but consuming them as per need) and poor (patient is not taking any prescribed analgesic or otherwise). No standard tool was used to grade the compliance of analgesics. Reasons for the poor compliance were also identified during the interview. Data regarding current disease status and the cancer treatment were extracted from the patient's medical records. Treatment adequacy was determined by assessing the pain relief at 30 min (PR30) after administration of analgesic and time required to achieve 50% or more pain relief (T50). Pain scores and analgesics prescribed at the time of discharge from the ED were noted. A case record form with following details was completed after each interview:
Analysis of variables
Data was collected in the form of numbers and percentages and were analyzed to derive the values of median, range and inter-quartile range (IQR).
A total of 51 male and 49 female patients were included in this study. The details of disease (e.g., types and stages of cancers) and cancer treatment are shown in [Figure 1] and [Figure 2] respectively. Forty five patients (45%) had cancer pain due to the tumor and were yet to receive any cancer therapy. Nine patients (9%) presented with pain due to tumor recurrence or metastasis at the same or a newer site after completing their primary cancer therapy. Rest of the 46 patients (46%) was receiving cancer therapy in the form of surgery or chemotherapy or radiotherapy. Out of these, 14 patients had undergone surgery, 29 patients were receiving chemotherapy (11 on taxanes, 18 platinum compounds and 4 on vincristines) and 9 patients were receiving radiotherapy.
Presenting pain details
No formal assessment and documentation of pain score was done by the ED health-care staff. Later, the investigator evaluated pain severity on NRS and found that 65% patients had severe pain (NRS ≥ 7) and the rest (35%) had moderate pain (NRS 4-6) [Figure 3]. Median pain score was 7 (range: 5-10, IQR 2). Somatic pain (well defined, clearly localized, sharp pain) was noted in 44 patients, out of which 26 patients had neuropathic pain component diagnosed on clinical characteristics. Visceral pain (poorly localized, diffuse pain) was noted in 56 patients, with 11 patients having neuropathic component. Region-wise pain has been shown in [Figure 4]. Sixty eight patients (68%) reported intermittent pain and 32 patients (32%) had continuous pain throughout the day. Forty eight patients (48%) had breakthrough pain.
Details of present pain treatment
A total of 88 patients (88%) already had a prescription advised by doctors involved in their ambulatory cancer care (weak opioids: 17 patients, strong opioids: 4 patients, non-steroidal anti-inflammatory drugs (NSAIDs) and/or acetaminophen: 73 patients). However, only 5 (6%) patients were fully adherent to prescribed analgesics, 56 patients (63%) were partially adherent and 27 patients (31%) did not take any analgesic at all, in spite of ongoing pain. In these 27 patients, reasons for poor compliance were identified after an interview. Around 15 patients reported that there was no pain relief with prescribed analgesics, while 8 patients did not have stock of analgesics. The 14 patients were not aware about clock-wise consumption of analgesics. Three patients had side-effects such as nausea, vomiting and abdominal pain. [Figure 5] shows these grades of compliance toward analgesics.
Details of ED treatment and its adequacy
Average duration of stay in ED was 74 min. Out of 65 patients with severe pain, only 46 patients (70%) received IV analgesics and 33 patients (50%) received Step II analgesics (weak opioids/NSAIDS/acetaminophen etc.). None of the patient received IV morphine or fentanyl. Intravenous tramadol was the most commonly used analgesic (44%).
Median pain score on admission to ED was 7 with a range of 5-10 on NRS (0-10), which reduced to 3 (range 0-8, IQR 3) at the time discharge. Thus, ED treatment resulted in 51% improvement in pain score. [Figure 3] shows a comparison between pain scores on admission and those at discharge from ED.
Twenty one patients (21%) had <25% of pain relief, 73 patients (73%) had 25-50% pain relief at and only 5 patients (5%) had 50-75% pain relief at 30 min after an analgesic injection. At 1 h from time of analgesic administration, 74 patients (74%) could achieve >50% pain relief. However, 24 patients (24%) could never achieve more than 50% pain relief until the time of discharge from ED.
At the time of discharge, 36 patients received a prescription of weak opioids and 2 patients were prescribed oral morphine, 73 patients received a prescription of oral NSAIDs. Single analgesic was prescribed to 47 patients while a combination of two or more analgesics was prescribed to 40 patients.
Disposal of patients from ED
A total of 93 patients (93%) were discharged to home. Out of them, 28 patients had moderate pain (NRS 4-6) and 2 patients had severe pain (NRS 7-10) at the time of discharge. Seven patients (7%) were admitted to ward for diagnostic or therapeutic purposes. Fifteen patients (15%) were directed to the hospital pain clinic during routine hours.
This study found that the majority of patients reported severe pain in ED of cancer hospital. Lack of formal pain assessment and guidelines led to under-utilization of opioids resulting in inadequate analgesia during ED stay. According to our medical records, approximately 11,500 patients visited ED in 2010 and about 2200 patients (19%) had pain as a major presenting problem. A study by Bozdemir et al. showed that the most common presenting problem for cancer patients visiting in emergency settings was pain (24%).  Tsai et al. had found significant pain in 27.8% of patients visiting ED due to various reasons.  Pain was found to be the first of the top three complaints by cancer patients to seek emergency care in a study conducted at North Carolina (2011). 
Poor assessment of pain is the major reason for suboptimal pain management. In our study, a formal pain assessment using a pain scale was not performed by ED staff. 65% patients had severe pain when pain assessment was done by the principal investigator. Patients were not reassessed after analgesic administration for the response or side effects of the treatment. Baumann et al. had shown that use of a pain scale for assessment enhanced documentation of pain from 41% to 57%.  It was also shown that analgesic use increased from 25% to 36% and analgesics were administered more rapidly when pain scales were used.  Lack of assessment of ED pain often lead to under-estimation of pain and hence, under-treatment of pain as well. Hence, National Comprehensive Cancer Network (NCCN) clinical practice guideline for adult cancer pain recommends assessment and documentation of pain score using a formal pain scale.  Reassessment of pain scores after analgesic administration can find out treatment inadequacy and additional analgesics can be supplemented if required.
Suboptimal management of pain during ambulatory cancer treatment is one of the major reasons for ED visits. In our study, we found that 88 patients who had analgesic prescriptions advised by their doctors involved in their ongoing cancer care; however, only five patients were fully adherent to prescribed analgesics. We found that only four patients were prescribed a strong opioid despite severe pain; therefore, it was not surprising to find that patients had poor pain relief and hence, poor compliance to medication. Secondly, many patients were not explained about clock-wise analgesic consumption. Thirdly, patient's poor financial status resulted in lack of analgesic stocks and the compliance was furthered worsened by poor follow-up for pain complaints. All these factors could be responsible for their ED visit with severe pain. Adherence to World Health Organization ladder or NCCN guidelines  for treatment of pain during ambulatory cancer therapy can reduce ED visits. One of the major barriers for effective cancer pain management is lack of effective communication between patient and their doctors, which leads to irregular analgesic consumption, poor pain relief, unexpected side-effects and hence, poor compliance toward analgesics. Previously, done studies by Miaskowski et al. and Valeberg et al. have shown that only 40% of cancer patients are adherent to prescribed analgesic regime. , Education of patient and its caregiver about clock-wise analgesic consumption, expected side-effects of analgesics, early reporting of poor pain relief and regular follow-up for appropriate analgesics refill can decrease the incidence of severe pain. 
Another major finding in this study is the reluctance to use strong opioids by physicians for control of severe pain. Despite the availability of strong opioids like morphine and fentanyl injections, none of the patients received these drugs to achieve rapid control of pain. IV tramadol 100 mg was the most commonly (44%) used drug to treat severe pain. This may be due to irrational fear of physicians about opioids and its related side effects, commonly known as "opiophobia".  A South Korean study (2011) revealed that a large population of young doctors showed a negative attitude and inadequate knowledge about cancer pain management. The important barriers to optimal cancer pain management were the fear of tolerance, addiction and knowledge deficit about opioids and their side-effects. 
The key to successful pain management in ED is to achieve rapid and satisfactory pain control by gradually titrating pain by small IV boluses of strong opioids and to prescribe adequate oral analgesics after calculating the requirement for 24 h basis. Mercadante showed that IV morphine boluses are effective in different clinical situations like breakthrough pain, patients with poor pain control with escalating doses of oral opioids or optimizing opioid therapy to prevent incident pain, etc.  IV morphine has rapid and predictable effect in pain control. NCCN guidelines for pain control also include IV morphine boluses in titrated manner to control severe pain.  In our study, such IV boluses were not used at all and only two patients were prescribed oral morphine tablets at the time of discharge. Later, a pain scale assessment by the investigator demonstrated that 24% patients could never achieve >50% pain relief at the time of discharge. Such inadequacy of treatment ("oligoanalgesia") was first described by Wilson and Pendleton.  A large study (pain and emergency medicine initiative, 2007)  highlighted the similar problems in management of pain in ED. Only 60% of patients received analgesics after lengthy delays (median - 90 min; range 0-962 min) and 74% of patients were discharged in moderate to severe pain.  Therefore "oligoanalgesia" and "opiophobia," which were noted long back, are commonly prevalent complex pain issues and need urgent solution by an effective pain education.
Lack of a universally accepted protocol for pain management in ED has resulted in inconsistent and inadequate treatment. In our study, we found that pain treatment decisions in ED were made by individual physicians who often have no pain education. Goodacre and Roden. had shown that a pain protocol implementation reduced unsatisfactory analgesia from 91% to 69% patients and enhanced the use of IV analgesics from 9% to 37%.  Few researchers had implemented institutional based protocols during their research. Hagen et al.  and Soares et al.  used IV morphine and fentanyl intermittent boluses respectively to achieve successful pain control in ED. However, both were small studies. NCCN clinical practice guideline for adult cancer pain provides a protocol in the form of an algorithm. As per this guideline, severe uncontrolled pain is a medical emergency and should be responded to promptly.  The guideline also recommends the intravenous use of strong opioid like morphine for the control of severe pain. Reassessment of pain intensity must be performed at regular intervals to ensure that the selected analgesic therapy is having maximum benefit with few adverse side effects.  Thus, we recommend that NCCN guidelines for acute cancer pain management should be implemented in the ED. Pain assessment using a pain scale should be a standard practice in ED and treatment should be based on pain severity. Strong opioids like morphine or fentanyl should be administered intravenously as small boluses to titrate pain in patients with severe cancer pain till the pain is under satisfactory control. Patients should be monitored for vital parameters. Amount of strong IV opioid required to titrate pain to a satisfactory level should be converted (using equianalgesic table) to oral analgesic dose per day and be prescribed at the time of discharge. Formal education of ED staff and doctors about cancer pain management would go a long way to improve patient satisfaction.
Few limitations of this study should also be acknowledged. Major limitation of the present study is the small sample size and the other methodological limitation is that all patients were not enrolled consecutively. Hence, prevalence of emergency cancer pain could not be estimated. As screening was done by ED nurse, there could be under reporting of pain. Health literacy of patients was not assessed and a standardized tool was not used for measurement of compliance. After discharge, patients could not be followed-up for evaluation of pain treatment adequacy.
This study shows that the majority of patients in ED had severe pain. Due to the lack of formal pain assessment and laid down protocols, suboptimal pain management is commonly prevalent. Strong opioids are not used even in severe pain scenarios as found in ED. Pain education to physicians, nurses and patients will go a long way in improving pain management and patient's satisfaction. Large studies are required to identify true prevalence of pain and optimal treatment in ED.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]