Article

Prevalence and treatment of anxiety among emergency department patients with pain

Correspondence / American Journal of Emergency Medicine 36 (2018) 13001320 1315

that “take the headache away”. Studies that only measure pain relief on a continuous scale may not capture this aspect. Patients also valued rapid and durable relief, highlighting the importance of measuring time to relief and frequency of headache relapse after initial successful treatment. This underscores the importance of meaningful follow-up of migraineurs post-ED visit. Finally, side effects were very important to patients. These should be actively, and perhaps quantitatively measured. Common side effects should be asked about specifically. Investigators should be mindful of the tradeoffs inherent in the currently available selection of parenteral migraine medication. The question of which endpoints to use in migraine clinical trials is the subject of a guideline document [2], in which two hour headache freedom is recommended as the primary outcome, with the ca- veat that trials of parenteral medication can obtain this outcome at an earlier time point. It is clear from our study, however, that relying solely on two hour headache freedom would fail to capture the medication ex- perience of many of our patients.

Table 1

Patient characteristics.

Patient characteristic

Value

Female sex n (%)

123 (81%)

Age in years, mean (SD)

40 (13)

Preferred language n (%) English

126 (83%)

Spanish

25 (17%)

Age of onset of migraines in years, median, IQR

20 (15, 33)

Number of different EDs visited previously for migraine n (%) 1

88 (58%)

N 1

63 (42%)

Conflict of interest statement

No conflict for any author.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2017.11.039.

Benjamin W. Friedman, MD, MS?

Jayson Lian, BA Eddie Irizarry, MD Sadiya Mayat, AGNP, MS Karolyn Rosa, MD

Polly E. Bijur, PhD

E. John Gallagher, MD Department of Emergency Medicine and Medical College, Albert Einstein College of Medicine, Montefiore Health System, United States

?Corresponding author at: Department of Emergency Medicine,

Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, United States.

E-mail addresses: [email protected], @benjaminbwf

(B.W. Friedman).

Prevalence and treatment of anxiety among emergency department patients with pain?

Emergency departments (ED) seek opportunities to further under- stand and improve the treatment of pain and reduce opioid administra- tion. Recent studies have shown that patients with untreated anxiety report higher pain scores and lower satisfaction during the ED visit de- spite similar doses of Opioid pain medications [1-4]. We evaluated the prevalence of anxiety among ED patients experiencing pain and the ED treatment of anxiety.

We performed a three-year, prospective evaluation of patients present- ing to the University of Utah ED with a pain-related complaint. Patients pro- vided baseline information at the time of ED presentation and follow-up information near the time of discharge or admission from the ED. We uti- lized a 0 (none) to 10 (maximum) scale for patients to report pain and anx- iety scores. Our primary outcome measures included the prevalence of anxiety in ED patients with pain, the proportion of these patients who would be willing to take medication for anxiety, and the number who re- ceived treatment for anxiety. Secondary outcomes included changes in pain and Anxiety scores among those who reported receiving treatment.

A total of 1132 patients with a pain-related complaint agreed to par- ticipate in the study. Average patient age was 46.4 years (range: 18- 97 years) and 57.5% of patients were female. Sources of pain included: abdominal/flank pain (45.7%), orthopedic pain (20.1%), back/neck pain (19.5%), headache (10.5%), and chest/rib pain (4.2%). The average initial pain score was 6.4 (95% CI: 6.2-6.5). Of all study patients, 33% also re- ported anxiety with an average initial anxiety score of 5.8 (95% CI: 5.5-6). Patients who reported anxiety had higher initial pain scores than those without anxiety (6.9 vs. 6.2, p b 0.001).

Of all study patients, 54.6% received pain medication in the ED. Pain medication administration rates were similar between patients reporting anxiety and those without anxiety (56.5% vs. 53.6%, p = 0.356). Among those who reported receiving pain medication, 58.7% re- ceived an opioid pain medication in the ED. Patients reporting anxiety were just as likely to receive an opioid pain medication as those who did not report anxiety (58% vs. 59.1%, p = 0.804).

Patients with anxiety who received pain medication reported similar improvements in their pain scores to those without anxiety (1.9 point difference vs. 1.8 point difference, p = 0.459). However, these patients

25 June 2017

https://doi.org/10.1016/j.ajem.2017.11.039

References

  1. Orr SL, Friedman BW, Christie S, Minen MT, Bamford C, Kelley NE, et al. Management of Adults with acute migraine in the emergency department: the American headache soci- ety evidence assessment of parenteral pharmacotherapies. Headache 2016;56(6):911-40.
  2. Tfelt-Hansen P, Pascual J, Ramadan N, Dahlof C, D’Amico D, Diener HC, et al. Guide- lines for controlled trials of drugs in migraine: third edition. A guide for investigators. Cephalalgia 2012;32(1):6-38.

Fig. 1. Comparison of initial and follow-up pain scores between patients reporting anxiety and those reporting no anxiety who received treatment for their pain.

? This study was presented at the Annual Meeting of the Society for Academic Emergency Medicine, May 16-19, 2017, Orlando, FL.

1316 Correspondence / American Journal of Emergency Medicine 36 (2018) 13001320

Fig. 2. Breakdown of patients with pain to those receiving medication for anxiety.

Fig. 3. Comparison of follow-up pain scores between patients with anxiety who received pain and anxiety medications (“Anxiety and Pain Medications” group) to patients without anxiety who received pain medication (“Pain Medications” group).

continued to report higher follow-up pain scores than those without anxiety who were treated for pain (5.5 vs. 4.8, p = 0.003) [Fig. 1].

Of those reporting anxiety, 71% of patients said they would be willing to take a medication for anxiety in the ED. Compared to all study patients, those willing to take an anxiety medication had higher initial pain scores (7.0 vs. 6.2,p b 0.001). Patients willing to take an anxiety medication were more likely to have a home prescription to treat anxiety (56.5% vs. 18.5%, p b 0.001) and had higher initial anxiety scores (6.1 vs. 4.9, p b 0.001) than those with anxiety who were unwilling to take an anxiety medication. Only 14.2% of patients with anxiety who were willing to take an anx- iety medication received treatment for anxiety [Fig. 2]. Despite having higher initial pain scores, those with anxiety who received medications for anxiety and pain had similar follow-up pain scores to those without anxiety who received pain medication (4.9 vs. 4.8, p = 0.791) [Fig. 3]. Those who were willing to take medication for anxiety and who re- ceived this medication reported a greater improvement in their anxiety scores than those who were not treated for anxiety (2.9 points vs. 1.8

point, p = 0.034).

A primary aim of addressing anxiety in the ED is to more effectively treat patients’ pain and to potentially reduce the ED administration of opioid medications and outpatient prescriptions for these medications [5-7]. Given the improved pain scores among those whose anxiety was treated, efforts to recognize and treat anxiety may further the goal of reduced opioid use in ED patients.

In reviewing the results of this study, clinicians may experience some hesitation in treating ED patients with an additional medication which has the potential for abuse. In our study, more than half of patients who were willing to take an anxiety medication reported having a home pre- scription for anxiety. In some cases, addressing anxiety may have been as simple as providing a missed dose of this medication. Additional non- medication approaches to anxiety may prove effective as well [8-10].

In summary, our study demonstrated that, despite a high prevalence of anxiety among ED patients with a pain-related complaint, few pa- tients received treatment for anxiety in the ED. The large majority of pa- tients with anxiety were willing to take a medication to treat their anxiety. Those who received anxiety treatment reported greater im- provement in their pain scores. Future studies may wish to explore anx- iety-related interventions as a means of reducing opioid administration in the ED.

Katie Wells, MD, MPH Philip Craven, MD

Jacob Steenblik, MPH, MHA Margaret Carlson, BS Caitlynn Cooper, BSN Troy Madsen, MD?

University of Utah Medical Center, Division of Emergency Medicine, Salt

Lake City, UT, United States

*Corresponding author at: University of Utah, Division of Emergency Medicine, 30 N. 1900 E. 1C26, Salt Lake City, UT 84132, United States. E-mail address: [email protected] (T. Madsen).

16 August 2017

https://doi.org/10.1016/j.ajem.2017.11.042

Correspondence / American Journal of Emergency Medicine 36 (2018) 13001320 1317

References

  1. Craven P, Cinar O, Madsen T. Patient anxiety may influence the efficacy of ED pain management. Am J Emerg Med 2013;31:313-8.
  2. Kapoor S, White J, Thorn BE, Block P. Patients presenting to the emergency depart- ment with acute pain: the significant role of pain catastrophizing and state anxiety. Pain Med Jun 2016;17(6):1069-78.
  3. Tang J, Gibson SJ. A psychophysical evaluation of the relationship between trait anx- iety, pain perception, and induced state anxiety. J Pain 2005;6(9):612-9.
  4. Quartana PJ, Campbell CM, Edwards RR. Pain catastrophizing: a critical review. Ex- pert Rev Neurother 2009;9(5):745-58.
  5. Murthy V. Ending the opioid epidemic– a call to action. N Engl J Med 2016;375(25): 2413-5.
  6. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths — United States, 2010-2015. MMWR Morb Mortal Wkly Rep 2016;65: 1445-52.
  7. Cantrill S, Brown M, Carlisle R, Delaney K, Hays D, Nelson L, et al. Clinical policy: crit- ical issues in the prescribing of opioids for adult patients in the emergency depart- ment. Ann Emerg Med 2012;60:499-525.
  8. Johnson JR, Crespin DJ, Griffin KH, Finch MD, Rivard RL, Baechler CJ, et al. The effec- tiveness of integrative medicine interventions on pain and anxiety in cardiovascular inpatients: a practice-based research evaluation. BMC Complement Altern Med Dec 13 2014;14:486.
  9. Qaseem A, Wilt TJ, McLean RM, Forciea MA. for the Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and Chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2017. https://doi.org/10.7326/M16-2367 [Epub ahead of print 14 February 2017].
  10. Fein JA, Zempsky WT, Cravero JP, Committee on Pediatric Emergency Medicine and Section on Anesthesiology and pain medicine, American Academy of Pediatrics. Re- lief of pain and anxiety in pediatric patients in emergency medical systems. Pediat- rics 2012 Nov;130(5):e1391-05.

Goodbye to the SIRS, the reason why we do not need you

To the Editor,

We read with interest the enchanting article by Haydar and col- leagues [1], who designed an electronic health record study to explore the sensitivity and diagnostic timeliness of the Quick Sequential Sep- sis-related Organ Failure Assessment (qSOFA) score and compare it with the score of Systemic Inflammatory Response Syndrome in emergency department (ED) encounters diagnosed with sepsis. Fi- nally, the authors concluded that qSOFA performed poorly as a screen- ing tool for identifying sepsis in the ED. Though the study sounds scientific, we still have some different viewpoints to address.

To begin, though many biological indicators or scoring systems show a possible promising role in detecting sepsis, there had not been a gold standard diagnostic test existed for sepsis. 25 years had passed since the proposal of SIRS in the first definition of sepsis (Sepsis 1.0) [2] in 1991 to the creation of qSOFA in the latest definition of sepsis (Sepsis 3.0) [3] in 2016. In the article by Haydar et al., they defined infection on account of the history of antibiotic usage and defined sepsis based on Medicare Services diagnosis related Grouping (DRG). In the footnote of ‘DRG’ in Table 1, sepsis was defined as ‘SIRS with suspected source infection’ which was in accordance with the definition of Sepsis 1.0. So it is no wonder that SIRS showed better sensibility than qSOFA as SIRS itself was a composition of Sepsis 1.0 [1]. Furthermore, the category of ‘Sepsis DRG’ in Table 1 showed that 195(7 + 144 + 44) patients in total were included, however, the context indicated that the total number was 200, how to explain it?

Next, Haydar and coworker [1] found that the mean time from ED arrival to documented presence of SIRS and qSOFA was 47.1 min and

84.0 min respectively and concluded that the time to meet qSOFA criteria was significantly longer than for SIRS. Now let us review the constituents of the two famous scoring systems. SIRS [2] is made up of 4 elements – body temperature, heart rate, respiratory rate (or PaCO2) and white blood cell count (or immature band forms), thus it is a time-consuming score as laboratory examination is needed. While qSOFA [3] consists of only 3 elements – respiratory rate, altered mentation and systolic blood pressure, all are simple and available with- out any laboratory examination or additional apparatus except a

sphygmomanometer. The whole process of acquisition and calculation of qSOFA would be no more than 10 min, as a matter of fact, qSOFA was incorporated into the Sepsis 3.0 mainly due to its simplicity, quick- ness and availability. Based on the above, we believe that the time to achieve qSOFA will not be longer than the SIRS.

Besides, the authors in the commented study aimed to compare the diagnosing and predicting validity of qSOFA and SIRS in ED septic en- counters, nevertheless, no concrete time window had been specified in their study, in fact, both qSOFA and SIRS will change with time as their component variables (for example, heart rate) vary with time and it is crucial to decide which timepoint to act as a cutoff point. In the derivative study of qSOFA [4], the time window of 48 h before to 24 h after the onset of infection was chosen and the maximum SIRS criteria and SOFA score were calculated. In addition, it should be noted that there were 7 patients with severe sepsis and septic shock requiring mechanical ventilation as Table 1 indicated in the commented study, however, treatment strategies like mechanical ventilation could alter the values of SIRS or qSOFA score which should be cautious to interpretate.

What is more, Haydar et al. [1] found that 94.5% of their cohort met SIRS criteria whereas only 58.3% met qSOFA criteria in the ED and in- ferred that qSOFA performed poorly as a screening tool. We admit that qSOFA have an inadequate sensibility, as experts from the task force panel of Sepsis 3.0 pointed out that ‘qSOFA does not replace SIRS as a screening tool for sepsis because it was conceived, derived and val- idated as a Prognostic tool.’ [5] As Table 2 shows, for predicting in-hos- pital mortality of ED septic patients, SIRS had a very high sensitivity of 95.5% but an extremely low specificity of only 5.6% while the qSOFA had a high sensitivity of 90.9% together with a relative low specificity of 45.8%. The area under the receiver operating characteristic (AUROC) of SIRS and qSOFA score was 0.51 and 0.68 respectively, suggesting the qSOFA score seems to have a better prognosis predicting efficacy than the SIRS score and the SIRS score almost does not have the ability to predict the prognosis [6] (Just think that the probability of tossing a coin to get the obverse is 0.5). Actually, the term of ‘SIRS’ was formally abandoned by the task force panel of Sepsis 3.0 because it was too sen- sitive and not specific [3], which got further verified in this commented study.

The last, we appreciate Haydar et al. for their innovative and mean- ingful study, but the interpretation of their work should be cautious and further rigorous studies are still warranted.

Abbreviations

qSOFA Quick Sepsis-related Organ Failure Assessment SIRS Systemic Inflammatory Response Syndrome ED emergency department

DRG Diagnosis Related Grouping

AUROC area under the receiver operating characteristic

Ethical approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Availability of supporting data

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Leave a Reply

Your email address will not be published. Required fields are marked *