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Emergency and Acute Medicine – Pain (Principles, Medications, and Comfort Care)
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, dysfunction of the somatosensory system, or psychogenic factors. It is inherently subjective and multifactorial, influenced by culture, prior medical experiences, beliefs, mood, and coping mechanisms. Pain is the most common reason for seeking medical care and accounts for up to 78% of emergency department (ED) visits, with two-thirds of patients reporting severe pain. Chronic pain affects up to one-third of the general population, and neuropathic pain is present in more than 20% of ED encounters.
Pain can arise from different mechanisms, often coexisting in the same patient. Nociceptive pain results from stimulation of peripheral nociceptors due to actual or threatened tissue injury. Visceral pain is diffuse, poorly localized, often referred, and described as deep, squeezing, or dull. Deep somatic pain originates from ligaments, bones, muscles, and fascia and is typically aching and poorly localized, whereas superficial pain from the skin is sharp and well defined. Neuropathic pain is caused by injury or dysfunction of the nervous system and may present with allodynia, electric shock–like sensations, burning, coldness, paresthesias, numbness, or itching. Psychogenic pain is influenced or prolonged by emotional, behavioral, or psychological factors.
Assessment of pain relies primarily on the patient’s self-report, which is the most reliable measure. A detailed history should include onset, mechanism of injury if applicable, location, intensity, quality, duration, variations over time or with activity, and response to prior analgesics. Pain intensity is commonly quantified using the Numerical Rating Scale (0–10), Visual Analog Scale, or the Faces Pain Scale in children. Clinically meaningful improvement generally corresponds to a reduction of at least 1.5 points on a 10-point scale. Screening tools such as the DN4 questionnaire help identify neuropathic pain. In nonverbal patients, pain assessment depends on observation of facial expressions, vocalization, posture, protective behaviors, and movement.
Physical examination should be performed gently and systematically, beginning with uninjured areas and progressing cautiously to painful regions. The examiner should warn the patient before each maneuver, avoid sudden movements, and repeat the examination after analgesia, as pain relief often improves diagnostic accuracy. Diagnostic tests, laboratory studies, and imaging should be guided by the suspected underlying condition rather than pain alone.
Management of pain in the emergency setting prioritizes rapid relief while simultaneously addressing life-threatening conditions. Nonpharmacologic measures such as immobilization, elevation, ice application, reassurance, and anxiety reduction are effective and should be used routinely. Pharmacologic therapy is tailored to pain severity and etiology. Acetaminophen is safe and effective for mild to moderate pain, while NSAIDs are useful for musculoskeletal pain and renal or biliary colic but carry risks of gastrointestinal bleeding and renal injury. Opioids are indicated for severe pain and are best administered intravenously with careful titration due to wide interindividual variability. Oral opioids may be appropriate for less severe pain or for discharge planning. Regional anesthesia should be considered for well-localized pain such as fractures, dental pain, or extremity injuries.
Disposition depends on the underlying medical condition and adequacy of pain control. Admission is warranted for patients with uncontrolled pain or conditions requiring inpatient management. Discharge is appropriate when pain is reduced to an acceptable level for the patient, typically defined as a pain score of 3/10 or less or a reduction of at least 50% from baseline. Careful attention should be paid to opioid conversion when transitioning from intravenous to oral therapy, and scheduled dosing with additional as-needed medication is preferred for sustained pain control.
Key principles in emergency pain management include initiating analgesia early—especially in severe pain—using regular reassessment to guide therapy, combining pharmacologic and nonpharmacologic strategies, and titrating opioids appropriately to achieve rapid and effective relief. Persistent or recurrent pain despite appropriate treatment should prompt reassessment of the diagnosis and consideration of alternative or evolving pathology.
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