Pain has been identified as the most common reason for patients seeking care in emergency rooms. Considering the substantial impact that pain has on patients, ED physicians need to be well versed in its management, particularly in acute pain situations. Unfortunately, research has shown that ED physicians often fail to provide adequate analgesia to their patients. There are also challenges in meeting patients’ expectations in treating pain and in changing prescribing patterns of opioid analgesics.

The Effects of “Oligoanalgesia”

We have more than 25 years of research on acute pain management as well as multiple guidelines on the topic. Despite this information, the phenomenon of “oligoanalgesia”— the undertreatment of pain—continues to persist in EDs. The following are major causes of oligoanalgesia in the ED:

Lack of basic knowledge and formal education on acute pain management.
Prejudice toward and irrational fear of using opioids in the ED.
Lack of adherence to acute pain management guidelines and clinical pathways.
Underuse of analgesics titration protocols.

Barriers preclude ED physicians from proper acute pain management that include ethnic, racial, and age bias as well as ED environment and culture.

Wanted: More Formal Pain Management Training

The lack of formal teaching of acute pain management in medical schools has had a profound effect on the gap in emergency physicians’ clinical knowledge on the subject. There may also be a reluctance to change practice patterns or a prejudice toward using opioid analgesics in the ED. Pain management is a subject that is not taught within most medical school programs. Research has shown, however, that utilizing pain management educational programs can lead to substantial improvements (see also, Pain Management: A Look at Provider Perspective). More efforts are needed nationwide in creating pain management curriculum in medical schools and residencies.

Environment & Culture Affect Pain Management

Crowding, interruptions, and break-in tasks are common problems in the ED that can lead to delays in treatment as well as delivery of pain medications. Other cultural factors that affect pain management include poor doctor–patient communication, stereotyping and prejudices, patient mistrust issues, and patient dissatisfaction. These factors must be regularly assessed and altered, if need be, based on characteristics unique to each ED setting so that pain management protocols can be developed to improve outcomes (see also, Striving Toward Quality Pain Management).

“Pain management, particularly acute pain, is simply a subject that is not taught within most medical school programs.”

We have a great responsibility to relieve pain by all possible appropriate means in a timely, efficient, and effective manner. More than a decade ago, the RELIEF approach to pain management was introduced by Turturro et al (Table). The take-home messages of the RELIEF approach should be applied in order to positively impact acute pain management in the ED. Oligoanalgesia will persist unless each physician assumes leadership in pain management. As we see improvements in pain assessment and documentation and progress in knowledge and research, the hope is that emergency physicians will more effectively manage acute pain in the ED.


Motov SM, Khan AN. Problems and barriers of pain management in the emergency department: are we ever going to get better? J Pain Res. 2009; 2:5-11. Available at:

Turturro MA. Pain management in the ED: prompt, cost-effective, state-of-the-art strategies. Emerg Med Prac. 1999;1:1-16.

Rupp T, Delaney KA. Inadequate analgesia in emergency medicine. Ann Emerg Med. 2004;43:49403.

Todd KH, Ducharme J, Choiniere M, et al; PEMI Study Group. Pain in the emergency department: results of the pain and emergency medicine initiative (PEMI) multicenter study. J Pain. 2007;8:460-466.

Fosnocht DE, Swanson ER, Barton ED. Changing attitudes about pain and pain control in emergency medicine. Emerg Med Clin North Am. 2005;23:297–306.

Pines JM, Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008;51:1-5.

Chapman CR, Fosnocht D, Donaldson GW. Resolution of acute pain following discharge from the emergency department: the acute pain trajectory. J Pain. 2012 Jan 27. [Epub ahead of print].

Wilson JE, Pendleton JM. Oligoanalgesia in the emergency department. Am J Emerg Med. 1989;7:620-623.