Article

Patient anxiety may influence the efficacy of ED pain management

Unlabelled imageAmerican Journal of Emergency Medicine (2013) 31, 313-318

Original Contribution

Patient anxiety may influence the efficacy of ED pain management

Philip Craven MD?, Orhan Cinar MD, Troy Madsen MD

University of Utah, Salt Lake City, UT 84132, USA

Received 1 March 2012; revised 2 August 2012; accepted 5 August 2012

Abstract

Objective: The aim of this study was to evaluate the incidence of anxiety and rates of anxiety treatment in emergency department (ED) patients presenting with pain-related complaints.

Methods: We prospectively evaluated patients in an urban academic tertiary care hospital ED from 2000 through 2010. We enrolled a convenience sample of adult patients presenting with pain and recorded patient complaint, medication administration, satisfaction, and pain and Anxiety scores throughout their stay. We stratified patients into 4 different groups according to anxiety score at presentation (0, none; 1-4, mild; 5-7, moderate; 8-10, severe).

Results: We enrolled 10 664 ED patients presenting with pain-related complaints. Patients reporting anxiety were as follows: 25.7%, none; 26.1%, mild; 23.7%, moderate; and 24.5%, severe. Although 48% of patients described moderate to severe anxiety at ED presentation and 60% were willing to take a medication for anxiety, only 1% received anxiety treatment. Thirty-five percent of patients still reported moderate/severe anxiety at discharge. Severe anxiety at ED presentation was associated with increased demand for pain medication (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.10-1.79) and anxiety medication (OR, 4.34; 95% CI, 3.68-5.11) during the ED stay and decreased satisfaction with the treatment of pain (? coefficient = -0.328; P b .001). After adjusting for age, sex, and presentation pain scores, patients who reported severe anxiety were more likely to receive an analgesic (OR, 1.33; 95% CI, 1.19-1.50) and an opioid (OR, 1.25; 95% CI, 1.11-1.41) during the ED stay.

Conclusion: Anxiety may be underrecognized and undertreated in patients presenting with pain-related complaints. Patients reporting severe anxiety were less likely to report satisfaction with the treatment of their pain, despite higher rates of analgesic administration.

(C) 2013

Introduction

Pain is the most common presenting symptom, accounting for up to 78% of all emergency department (ED) visits [1,2]. Managing pain effectively continues to

* Corresponding author. Tel.: +1 3476334575.

E-mail addresses: [email protected], [email protected] (P. Craven), [email protected] (O. Cinar), [email protected] (T. Madsen).

be a challenge in the ED settings, and many studies have demonstrated that oligoanalgesia, or inadequate analgesia, is a problem for a broad spectrum of ED patients [2-5]. Identifying and minimizing the risk factors of oligoanalge- sia is an important step of improving ED pain manage- ment. Many factors such as age [6-8], sex [9], and ethnicity [10,11] have been described previously as risk factors of oligoanalgesia.

For many patients, pain may be a psychological process as much as a physical one. Anxiety and pain may dynamically affect one another, and the impact of anxiety in an ED setting

0735-6757/$ – see front matter (C) 2013 http://dx.doi.org/10.1016/j.ajem.2012.08.009

may be even more pronounced. Previous studies, partic- ularly from dentistry literature, have shown that there is a strong correlation with a patient’s anxiety and reported pain scores and patients’ anxiety must be addressed to adequately control their pain [12]. However, the effect of anxiety on the efficacy of pain management in the ED and physician effectiveness in the treatment of anxiety remains unclear. If anxiety is a risk factor for oligoanalgesia and dissatisfaction, evaluation of anxiety scores with pain scores at presentation may help the ED physician to recognize such patients early in their ED course and manage their symptoms properly.

The aims of the study were to evaluate the incidence of anxiety and the rates of anxiety treatment in ED patients presenting with pain-related complaints and to determine whether anxiety may affect pain management and patient satisfaction.

Methods

Study design

The study design included a 10-year prospective, observational study of patients who presented with pain- related complaint to the University of Utah Medical Center ED between September 2000 and April 2010. Patients were included in an ongoing quality improvement database maintained by the University of Utah Medical Center ED to evaluate the efficacy of the treatment of pain in the ED. The study was approved by the University of Utah Institutional Review Board.

Setting

The University of Utah Medical Center ED is an urban, academic, tertiary care hospital ED with an annual volume of 39 000 patient visits per year. A convenience sample of patients was enrolled, and data collected when trained research assistants were available. Patient information was collected 7 days a week, between 8 AM and midnight, over the 10-year period.

Selection of participants

Adult patients admitted with a chief concern of pain from any cause were included in the study. Specific chief concerns were not recorded, and only a primary or secondary complaint of pain was required for the study. Exclusion criteria included the following: patients younger than 18 years, patients with a critical illness, or patients meeting the criteria for trauma designation. In addition, patients with language or other comprehension barriers, prisoners, and patients electing not to participate for any reason were not included in the study.

Methods of measurement

All patients were given a questionnaire in which they were asked to quantify their pain on a scale of 0 to 10, with 0 signifying “no pain” and a score of 10 the “worst possible pain.” Patients were also asked to quantify their anxiety on a scale of 0 to 10, with 0 signifying “no anxiety” and a score of

10 the “worst possible anxiety.” Patients provided this information both at the time of ED presentation and at discharge. Patients were asked if they had taken any analgesic medication before ED presentation and if they were willing to take a medication for pain and anxiety. For the purposes of the study, pain medications were classified as “opioid” or “analgesic,” where analgesic encompassed any nonopioid medication such as acetaminophen, a nonsteroidal anti-inftammatory drug, and so on. Analgesia and anxiety medications that were used in the ED and discharge time were recorded from nursing records. Patient demographic information was recorded, including age, sex, and self- identified race. Patient satisfaction of overall ED experience was also elicited at discharge in a similar fashion on a 10- point scale, with 0 meaning “not satisfied with experience” and 10 meaning “most satisfied with experience.”

Outcome measures

Patients were stratified into 4 different groups according to their anxiety score at presentation (a scale of 0-10 scores: 0, none; 1-4, mild; 5-7, moderate; 8-10, severe). The outcome measures evaluated were pain, anxiety, and satisfaction scores and the pain and anxiety medication use in the ED.

Primary data analysis

Descriptive statistics are presented as frequency (percent- age) for categorical variables, and continuous data are presented as mean +- SD for normally distributed data and median (interquartile range] for nonnormally distributed data. Probability values were calculated using the ?2 test or a t test, and ORs express the relative risk that patients in the mild, moderate, and severe anxiety group had or experienced the designated variable. Logistic regression analyses were used for dichotomous outcomes, and linear regression analyses were used for continuous data. Multivariable adjustments of the association of anxiety with the specified outcomes were made for age, sex, and pain at presentation. SPSS 17.0 (SPSS Inc, Chicago, Illinois) was used for statistical analyses, and P b .05 was considered statistically significant.

Results

A total of 10 664 ED patients presented with pain-related complaints and were enrolled in the study. Patients reporting anxiety were as follows: 25.7%, none; 26.1%, mild; 23.7%,

moderate; and 24.5%, severe (Table 1). Although 48% of

Table 1 Study variables

by anxiety groups

Variable

Anxiety category

P

Overall

None (0)

Mild (1-4)

Moderate (5-7)

Severe (8-10)

Age (y)

39.2 +- 16.0

29.2 +- 16.6

38.4 +- 15.8

39.1 +- 15.8

40.1 +- 15.7

b.001

Sex (female)

54.2%

50.5%

51.4%

54.9%

60.5%

b.001

Pain at presentation

6.9 +- 2.5

6.6 +- 2.6

6.0 +- 2.5

7.0 +- 2.2

7.9 +- 2.2

b.001

Presentation anxiety

4.3 +- 3.5

0 +- 0

2.5 +- 1.1

5.9 +- 0.9

9.1 +- 0.9

b.001

patients described moderate to severe anxiety at ED presentation and 60% of them were willing to take a medication for anxiety, only 1% received anxiety treatment. Thirty-five percent of patients still reported moderate to severe anxiety at discharge (Table 2).

Higher pain scores were found to be related with higher anxiety scores both at presentation (6.6 vs 6.0, 7.0, and 7.9;

P b .001) and discharge (4.6 vs 4.2, 4.8, and 5.3; P b .001) (Table 2). Severe anxiety at ED presentation was associated with increased demand for pain medication (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.10-1.79) and anxiety

medication (OR, 4.34; 95% CI, 3.68-5.11) (Table 3) during the ED stay and decreased satisfaction with the treatment of pain (9.0 vs 8.8, 8.8, and 8.6; ? coefficient = -0.328, P b

.001) (Table 2).

Increasing age (29 years vs 38, 39, and 40 years; P b

.001), female sex (50.5% vs 51%, 54%, and 60.5%; P b

.001), chronic pain (38% vs 34%, 42%, and 47%; P b .001),

and higher presentation pain scores (6.6 vs 6.0, 7.0, and 7.9; P b .001) were associated with higher anxiety scores (Table 1).

After adjusting for age, sex, and presentation pain scores, patients who reported severe anxiety were more likely to receive an analgesic (OR, 1.33; 95% CI, 1.19-1.50) and an opioid (OR, 1.25; 95% CI, 1.11-1.41) during the ED stay (Table 2).

Table 2 Study outcomes by anxiety groups in univariable analysis

Variable Anxiety category

P

Overall None (0) Mild (1-4) Moderate (5-7) Severe (8-10)

Limitations

Study results are limited to the experience of one academic ED, which may affect the generalizability of the study. Emergency departments may differ in their pain managements practices and protocols, as well as in patient demographics and primary Presenting complaints. However, considering the prospective nature and the 10-year time frame of the study, it is felt that these results provide one of the more comprehensive evaluations of the effect of anxiety on pain management in the ED.

This study is also limited in that it was a convenience

sample of patients and was conducted based on the presence of research associates in the ED. Patients presenting with Intense pain, or those with significant comorbidities or illness severity, may have been less likely to agree to participate in the study. Failure to include patients presenting between midnight and 8 AM may additionally introduce the potential for selection bias.

The study did not take into account whether or not the patient already had an underlying diagnosis of anxiety or if he/she was currently being treated as an outpatient with a psychotropic. As such, it is unknown as to whether or not a patient with a prior diagnosis of anxiety was more likely to report to the ED resulting in increased incidence and higher severity of anxiety complaints. Specific chief concerns were

Chronic pain

40.3%

38.4%

34.3%

42.1%

47.1%

b.001

Prior pain medication

44.2%

42.0%

43.7%

44.8%

46.3%

.015

Willing to take anxiety medication

59.6%

43.6%

50.0%

67.1%

79.1%

b.001

Needed pain medication

67.2%

64.7%

56.8%

69.5%

79.8%

b.001

Medication relieves your pain

80.8%

82.6%

84.2%

79.6%

77.2%

.049

Ask for pain medication

37.6%

34.8%

31.5%

38.6%

47.0%

b.001

Need additional pain medication D/C

44.3%

42.0%

37.5%

47.9%

51.2%

b.001

Analgesic

49.3%

44.5%

43.0%

51.7%

58.6%

b.001

Opioid

38.8%

34.7%

32.2%

41.4%

47.5%

b.001

Pain at discharge

4.7 +- 2.8

4.6 +- 2.9

4.2 +- 2.6

4.8 +- 2.7

5.3 +- 2.9

b.001

Expect for pain relief

2.6 +- 2.3

2.5 +- 2.2

2.6 +- 2.1

2.7 +- 2.1

2.6 +- 2.3

b.001

Discharge anxiety

2.8 +- 3.1

0.9 +- 2.2

1.9 +- 2.2

3.7 +- 2.8

5.0 +- 3.5

b.001

Overall satisfaction

8.8 +- 2.0

9.0 +- 1.9

8.8 +- 1.8

8.8 +- 2.0

8.6 +- 2.3

b.001

Data are given as median (interquartile range), and P values are from a test of natural log-transformed variables by ANOVA.

OR (95% CI)

P

OR (95% CI)

P

OR (95% CI)

P

Chronic pain

0.96 (0.85, 1.08)

.50 ?

1.12 (0.99, 1.26)

.07 ?

1.20 (1.06, 1.35)

.0039 ?

Prior pain medication

1.13 (1.01, 1.26)

.027 +

1.10 (0.98, 1.23)

.09 ?

1.08 (0.97, 1.21)

.16 ?

Willing to take anxiety medication

1.42 (1.23, 1.65)

b.001 ?

2.63 (2.26, 3.06)

b.001 ?

4.34 (3.68, 5.11)

b.001 ?

Needed pain medication

0.80 (0.65, 0.98)

.033 ?

1.04 (0.83, 1.29)

.75 ?

1.40 (1.10, 1.79)

.0060 ?

Medication relieves your pain

1.15 (0.78, 1.69)

.49 ?

0.85 (0.59, 1.24)

.41 ?

0.69 (0.48, 0.99)

.043 ?

Ask for pain medication

0.98 (0.80, 1.20)

.85 ?

1.08 (0.88, 1.32)

.46 ?

1.23 (1.01, 1.50)

.049 +

Need additional pain medication D/C

0.90 (0.78, 1.05)

.19 ?

1.14 (0.98, 1.33)

.08 ?

1.08 (0.92, 1.26)

.35 ?

Analgesic

1.15 (1.03, 1.29) .016 ?

1.23 (1.10, 1.38)

b.001 ?

1.33 (1.19, 1.50)

b.001 ?

Opioid

(B) Linear outcomes

1.11 (0.99, 1.27) .08 ?

1.23 (1.09, 1.38)

b.001 ?

1.25 (1.11, 1.41)

b.001 ?

Outcome

Anxiety category

Mild (1-4)

Moderate (5-7)

Severe (8-10)

? Coefficient P

? Coefficient

P

? Coefficient

P

Pain at discharge

-0.113

.17 ?

-0.124

.139 ?

-0.068

.43 ?

Expect for pain relief

0.286

b.001 ?

0.180

.0029 ?

-0.044

.47 ?

Discharge anxiety

1.034

b.001 ?

2.741

b.001 ?

3.973

b.001 ?

Satisfaction: discharge

-0.146

.11 ?

-0.279

.0025 ?

-0.193

.042 ?

Overall satisfaction

-0.191

.0046 ?

-0.228

.0010 ?

-0.328

b.001 ?

Results after adjustment for pain at presentation compared with patients with an anxiety score of zero (none) for dichotomous outcomes (A) (ORs and 95% CIs from logistic regression) linear outcomes (B) (effects given as the linear slope coefficient ? from linear regression).

* Results remained similar (either remained significant or remained nonsignificant) with adjustment for age, sex, and race.

+ Significance was lost (P N .05) after adjustment for age, sex, and race.

not recorded, and so no stratification can be done with regard to specific pain problems vs the prevalence of higher levels of anxiety. No data were collected regarding whether or not a patient required surgery or a procedure, or if he/she required admission vs discharge. As such, these data could not be used as a more objective means of quantifying pain. However, the present study does show that higher pain scores were associated with higher levels of anxiety, regardless of what the chief concern was.

Table 3 Study outcomes by anxiety groups in multivariable analysis

(A) Dichotomous outcomes

Outcome Anxiety category

Mild (1-4) Moderate (5-7)

Severe (8-10)

One minor limitation to the study was the assessment of the anxiety. Anxiety was measured with a self-reported 10- point rating scale that has not been validated. In retrospect, a specific anxiety scale such as the Hospital Anxiety and Depression Scale [13] or State-Trait Anxiety Index [14] may have provided more objective results. However, being that anxiety is a completely subjective symptom, it was felt that a subjective scoring system was sufficient. Owing to the study design and the subjective nature of the anxiety, no data regarding patient reported anxiety vs physician-“observed” levels were recorded.

Discussion

The results showed that anxiety is common among patients presenting to the ED with pain. This is evidenced by

the fact that only 25.7% of patients reported no anxiety in the ED, whereas 74.3% of patients had some form of anxiety ranging from mild to severe. Although it is not possible to know the exact etiology of the described anxiety, it is reasonable to assume that this anxiety was acute and relevant. Underlying psychiatric diseases may have also play a role; however, the impact of underlying disease should have been limited given that the estimated lifetime prevalence rates for individual anxiety disorders are 2.3% to 2.7% for panic disorder, 4.1 to 6.6% for generalized anxiety disorder, 2.3% to 2.6% for obsessive-compulsive disorder, 1% to 9.3% for posttraumatic stress disorder, and 2.6% to 13.3% for social phobia [15,16]. Thus, it would appear that this anxiety observed in the study was acute in relation to the ED visit. As such, no information regarding prior diagnosis of anxiety or prior chronic use of a psychotropic (Selective serotonin reuptake inhibitor, etc) was recorded.

Higher anxiety scores were found to be related to higher pain scores and increased demand for pain medication. These results are consistent with the previous studies showing a relationship between anxiety and pain. Kain et al [17], in their study that questioned whether postoperative pain could be predicted based on preoperative anxiety, found a positive correlation between the level of anxiety and postoperative

pain. In another study that used the event-related functional magnetic resonance imaging, Ploghaus et al [18] compared activation responses to noxious thermal stimulation while perceived pain intensity was manipulated by changes in either physical intensity or induced anxiety. They showed that hippocampal involvement from increased anxiety results in pain intensity amplification. Kain et al [19], in their randomized, controlled trial evaluating the effect of preop- erative anxiolytic use on postoperative parameters, demon- strated that pain and analgesic use were significantly decreased in the anxiolytic group for 1 week postoperatively. In an ED study, Oktay et al found that anxiety was related with higher pain perception. These findings support the idea that anxiety-reducing strategies as an adjunct to analgesic treatment may help to reduce the risk of oligoanalgesia in ED. In the present study, although 60% of the patients were willing to take a medication for anxiety, only 1% received anxiety treatment. The objective of the study was to examine the need for anxiety treatment in the ED setting. As such, the subset of patients that did receive anxiolytic treatment was not further examined. Further studies will be needed to assess the effectiveness of treatment. Reasons for the apparent underutilization of anxiolytic medications were not explored. However, it seems likely that in the ED setting, concurrent conditions such as hemodynamic instability or altered mental status may contraindicate an anxiolytic. Nevertheless, the results may indicate an important gap in ED practice in addressing and treating the emotional need of patients. Currently, standard emergency medicine texts suggest anxiolytic treatment if reassurance combined with an analgesic does not suffice in acute painful conditions for anxiety and feelings of loss of control [20]. The study results show that 35% of patients still reported moderate to severe anxiety at discharge. The very low rate of anxiolytic administration in the study suggests inadequate recognition

and treatment of anxiety in these patients.

Risk factors for increased anxiety in the ED were derived from the study. Increasing age (29-40 years), female sex, and chronic pain were associated with higher anxiety scores. These findings are consistent with previously reported demographic associations with generalized anxiety disorder [21].

Patients who reported severe anxiety were more likely to receive an analgesic and an opioid during the ED stay. That physicians are more likely to provide pain medication to a severely anxious patient is interesting. This result might be explained with the physicians’ diagnostic gestalt about anxiety and increased pain experience. One good example might be the children who need painful procedures in the ED. Anxiety may be more troubling than pain itself in children, and severe anxiety is one of the indications of Procedural sedation and analgesia in children [22]. Almost all ED physicians have had such an experience to form a gestalt about the relationship between anxiety and pain. Anxiety treatment before painful procedures in adult patients to reduce the pain experience is a topic worthy of further research.

In conclusion, it appears that increased anxiety is an important and previously unidentified risk factor for the oligoanalgesia in the ED. The study results show that anxiety may be underrecognized and undertreated in patients presenting with pain-related complaints. Furthermore, pa- tients reporting severe anxiety were less likely to report satisfaction with the treatment of their pain during the ED visit, despite increased odds of analgesic administration. Increased attention to anxiety in ED patients may result in improved treatment of pain and overall patient satisfaction.

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