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Abstracts (840) Pain in the emergency department: An online survey of patient experience K Todd, P Cowan, N Kelly; American Chronic Pain Association, Pittsburgh, NY Persons with chronic pain are frequently treated in the emergency department (ED), yet few researchers examine this experience. We invited visitors to the American Chronic Pain Association website to participate in a 40-item online survey concerning their experiences during ED visits. Of 248 respondents, 90% were white, 80% were female, and 84% were insured. Fully 44% had visited an ED three or more times within the past year. When asked why they visited the ED, 88% indicated that their pain was out of control and 54% stated they had contacted their personal physician for pain relief prior to their ED visit. A minority of respondents (16%) stated that their doctor told them to go to the ED. Their doctor indicated that he or she would no longer treat them in 19% of cases. In 30% of these instances, respondents felt that their physicians were afraid to treat them because of the high doses of analgesics required and in 34% physicians told them they had “done all they could.” On ED arrival, 98% reported severe pain intensity (NRS 7 or greater). 70% expected to be offered something for pain relief within 30 minutes of ED arrival and 58% expected to experience pain relief within 30 minutes; however, 64% reported waiting longer than one hour to be seen, and 43% waited longer than two hours to receive analgesics. Only 44% of respondents felt they were treated with dignity and respect by the ED staff and only 22% stated they were satisfied with their treatment. In terms of pain management, 47% rated their ED visit as “poor,” “terrible,” or “the worst experience of my life.” This preliminary survey highlights the many challenges faced by those seeking relief from chronic pain and a marked mismatch between patient expectations and the ED treatment of pain.
S61 (842) Pain in the emergency department: A multicenter study K Todd, C Crandall, M Choiniere, J Ducharme, D Fosnocht, P Homel, P Tanabe; Northwestern Memorial Hospital, Chicago, IL Pain is the single most common reason for emergency department (ED) use. Oligoanalgesia is common; however, no prospective multicenter study has examined this phenomenon. We conducted a multicenter, prospective, observational study of pain management among ED patients eight and older presenting with moderate to severe pain (NRS⬎3) who were ultimately discharged home. After informed consent, subjects underwent structured interviews and medical records were abstracted. Twenty hospitals in the U.S. and Canada participated and 842 subjects were enrolled. The majority were women (56%) and median age was 34.5 years (range 8 to 91). On ED arrival, median patient-reported pain intensity was severe (8, IQR 6 to 9) and on discharge, median pain intensity remained moderate (6, IQR 3 to 8). Pain assessments were noted in the medical record in 83% of cases; however, documented reassessments during the ED stay were uncommon (2 assessments for 31%, 3 assessments for 14%). Only 61% (N⫽506) of subjects received analgesics and these were administered after lengthy delays (median 90 minutes, mean 119 minutes). These 506 subjects received 735 doses of 27 different analgesics. Opioids were administered more commonly than nonopioids (60% vs. 40%), morphine being the most commonly used analgesic (21%), followed by ibuprofen (17%). Only 55% of subjects recalled that ED staff stressed the importance of pain treatment and 61% recalled being told that they should inform the ED staff about their pain. Of subjects not receiving analgesics, 42% felt they needed medication while only 15% actually requested medication. We conclude that presenting ED pain intensity is high and that pain is uncommonly reassessed during the ED stay. Analgesics are underutilized and delays to treatment are common. Staff communications regarding the importance of pain relief are insufficient and patients are unlikely to voice requests for analgesics. Much remains to be done in this area.
(841) Intradermal botulinum toxin, type B, for treating migraines of cervical origin
(843) A cost-utility analysis of conservative chronic spinal pain management
J Krusz, S Hall, J Cagle; Anodyne Headache and PainCare, Dallas, TX Botulinum toxin, type B, was given intradermally for migraines of cervical origin. All study patients had cervical muscle spasm. This doubleblind study follows up on prior open-label studies. 40 patients were entered. 16 each received intradermal botulinum toxin, type B, 2500 units and 5000 units, respectively. 8 patients received placebo. Intradermal toxin was given over the site of the greater and lesser occipital nerves on the side of predominant migraine headaches. After 1 month, all 8 placebo patients elected to receive 5000 units and be followed for 3 months. The migraine frequency and severity was assessed monthly at followup using headache diary cards. Both 2500 unit and 5000 unit dosing, compared to placebo, showed highly statistically significant reductions of migraine frequency as well as severity at the first time point (1 month after injection) and maintained at the last study visit, 3 months after intradermal botulinum toxin, type B. Headache reductions in frequency were p⬍.001 for both strengths of botulinum toxin, type B. Reductions in migraine severity continued at p⬍.01 and p⬍.02 [2500units and 5000 units, respectively] compared to placebo. All patients reported relief of muscle spasm over the entire course of the study. We conclude that intradermal administration of botulinum toxin, type B, reduced both frequency and severity of migraines of cervical origin. This new way of dosing botulinum toxin, type B, replicates and extends, in a double-blind fashion, our original open-label data with the same type of migraine headaches. Safety and tolerability of intradermal botulinum toxin, type B, are excellent. This dosing of botulinum toxin, type B, for migraines of cervical origin suggests mechanisms of action of the toxin that do not utilize motor nerve elements and may involve alterations in pain transmission pathways, as has been demonstrated in the case of glutamate, Substance P and CGRP release.
A Hatten, R Gatchel, P Polatin, A Stowell; UT Southwestern, Dallas, TX The present retrospective case review study sought to analyze the costutility, expressed in Cost/Quality-adjusted life years (QALYs), of current conservative chronic spinal pain treatments, as well as the QALY’s value as a clinically informative outcome measure. In addition, it expands upon previously published data evaluating the efficacy of interdisciplinary pain management, relative to medication management, in reducing the quantity and category of medication use. A recently developed algorithm was used to calculate QALYs using SF-36, v. 2 responses for 121 patients receiving treatment for chronic spinal pain at a pain rehabilitation center. Treatment groups evaluated were: (1) interdisciplinary program completers who also received medication management and supplementary anesthetic procedures; (2) interdisciplinary program completers also receiving medication management, but not anesthetic procedures; (3) patients receiving medication management alone; and (4) patients receiving medication management with supplemental anesthetic procedures. Assessments were conducted at pre-treatment and six-months after the initiation of treatment. Cost-utility analyses revealed that the interdisciplinary treatment alone group was cost-saving, relative to the medication and procedures alternative, suggesting the former modality was both less costly and more effective than the latter. Average cost-utility ratios for both interdisciplinary treatment groups, ranging from $57,627/QALY to $75,885/QALY, were within established cost-effective parameters ($20,000 to $100,000/QALY, generally considered a good value), while cost-utility ratios for the standard care treatment groups were not interpretable due to a decrease in QALYs from pre-treatment to post-treatment. Furthermore, pre- and post-treatment QALYs significantly correlated with well-developed measures of pain experience and functional disability, highlighting the QALY’s clinical utility as a measurement of patient health and well-being. Finally, posttreatment differences in the patients’ medication use were revealed among the four conservative spinal pain treatment groups.
S61 (842) Pain in the emergency department: A multicenter study K Todd, C Crandall, M Choiniere, J Ducharme, D Fosnocht, P Homel, P Tanabe; Northwestern Memorial Hospital, Chicago, IL Pain is the single most common reason for emergency department (ED) use. Oligoanalgesia is common; however, no prospective multicenter study has examined this phenomenon. We conducted a multicenter, prospective, observational study of pain management among ED patients eight and older presenting with moderate to severe pain (NRS⬎3) who were ultimately discharged home. After informed consent, subjects underwent structured interviews and medical records were abstracted. Twenty hospitals in the U.S. and Canada participated and 842 subjects were enrolled. The majority were women (56%) and median age was 34.5 years (range 8 to 91). On ED arrival, median patient-reported pain intensity was severe (8, IQR 6 to 9) and on discharge, median pain intensity remained moderate (6, IQR 3 to 8). Pain assessments were noted in the medical record in 83% of cases; however, documented reassessments during the ED stay were uncommon (2 assessments for 31%, 3 assessments for 14%). Only 61% (N⫽506) of subjects received analgesics and these were administered after lengthy delays (median 90 minutes, mean 119 minutes). These 506 subjects received 735 doses of 27 different analgesics. Opioids were administered more commonly than nonopioids (60% vs. 40%), morphine being the most commonly used analgesic (21%), followed by ibuprofen (17%). Only 55% of subjects recalled that ED staff stressed the importance of pain treatment and 61% recalled being told that they should inform the ED staff about their pain. Of subjects not receiving analgesics, 42% felt they needed medication while only 15% actually requested medication. We conclude that presenting ED pain intensity is high and that pain is uncommonly reassessed during the ED stay. Analgesics are underutilized and delays to treatment are common. Staff communications regarding the importance of pain relief are insufficient and patients are unlikely to voice requests for analgesics. Much remains to be done in this area.
(841) Intradermal botulinum toxin, type B, for treating migraines of cervical origin
(843) A cost-utility analysis of conservative chronic spinal pain management
J Krusz, S Hall, J Cagle; Anodyne Headache and PainCare, Dallas, TX Botulinum toxin, type B, was given intradermally for migraines of cervical origin. All study patients had cervical muscle spasm. This doubleblind study follows up on prior open-label studies. 40 patients were entered. 16 each received intradermal botulinum toxin, type B, 2500 units and 5000 units, respectively. 8 patients received placebo. Intradermal toxin was given over the site of the greater and lesser occipital nerves on the side of predominant migraine headaches. After 1 month, all 8 placebo patients elected to receive 5000 units and be followed for 3 months. The migraine frequency and severity was assessed monthly at followup using headache diary cards. Both 2500 unit and 5000 unit dosing, compared to placebo, showed highly statistically significant reductions of migraine frequency as well as severity at the first time point (1 month after injection) and maintained at the last study visit, 3 months after intradermal botulinum toxin, type B. Headache reductions in frequency were p⬍.001 for both strengths of botulinum toxin, type B. Reductions in migraine severity continued at p⬍.01 and p⬍.02 [2500units and 5000 units, respectively] compared to placebo. All patients reported relief of muscle spasm over the entire course of the study. We conclude that intradermal administration of botulinum toxin, type B, reduced both frequency and severity of migraines of cervical origin. This new way of dosing botulinum toxin, type B, replicates and extends, in a double-blind fashion, our original open-label data with the same type of migraine headaches. Safety and tolerability of intradermal botulinum toxin, type B, are excellent. This dosing of botulinum toxin, type B, for migraines of cervical origin suggests mechanisms of action of the toxin that do not utilize motor nerve elements and may involve alterations in pain transmission pathways, as has been demonstrated in the case of glutamate, Substance P and CGRP release.
A Hatten, R Gatchel, P Polatin, A Stowell; UT Southwestern, Dallas, TX The present retrospective case review study sought to analyze the costutility, expressed in Cost/Quality-adjusted life years (QALYs), of current conservative chronic spinal pain treatments, as well as the QALY’s value as a clinically informative outcome measure. In addition, it expands upon previously published data evaluating the efficacy of interdisciplinary pain management, relative to medication management, in reducing the quantity and category of medication use. A recently developed algorithm was used to calculate QALYs using SF-36, v. 2 responses for 121 patients receiving treatment for chronic spinal pain at a pain rehabilitation center. Treatment groups evaluated were: (1) interdisciplinary program completers who also received medication management and supplementary anesthetic procedures; (2) interdisciplinary program completers also receiving medication management, but not anesthetic procedures; (3) patients receiving medication management alone; and (4) patients receiving medication management with supplemental anesthetic procedures. Assessments were conducted at pre-treatment and six-months after the initiation of treatment. Cost-utility analyses revealed that the interdisciplinary treatment alone group was cost-saving, relative to the medication and procedures alternative, suggesting the former modality was both less costly and more effective than the latter. Average cost-utility ratios for both interdisciplinary treatment groups, ranging from $57,627/QALY to $75,885/QALY, were within established cost-effective parameters ($20,000 to $100,000/QALY, generally considered a good value), while cost-utility ratios for the standard care treatment groups were not interpretable due to a decrease in QALYs from pre-treatment to post-treatment. Furthermore, pre- and post-treatment QALYs significantly correlated with well-developed measures of pain experience and functional disability, highlighting the QALY’s clinical utility as a measurement of patient health and well-being. Finally, posttreatment differences in the patients’ medication use were revealed among the four conservative spinal pain treatment groups.