Benzodiazepine as a pain medication in emergency settings

Emergency departments frequently come across a wide range of patient with multiple types of presentations. The most common feature among them is pain, which may be acute or chronic. Acute pain can be due to appendicitis, or a gun shot wound, or acute exacerbation of a chronic pain. Chronic pain is usually in the cases of rheumatic arthritis, or cancer patients. Regardless of the type of the pain, the medical personnel are always needed to decide which pain medication is needed for a particular patient.

Understanding of individual drugs, their mode of action, their potency, and their possible interactions with the person’s condition or with other drugs is necessary to prevent any adverse consequences of prescribing. There are many pain killer drugs now available in the market. With the rapid progression in the pharmaceutical industry, there is a larger pool for the health care workers to prescribe from, and specification for all types of conditions. The UK government has since then put up many guidelines to help practitioners prescribe the right drug.

Since many of the drugs are given based on the intensity of the pain described by the patient, the use of pain scales is one of the key instruments in the measurement of pain. The efficacy of these pain measurement scales have been brought into question from time to time. However, up till now, very few if any alternatives have been as useful as this one. Apart from the administration of the pain killer drugs, there are many legal aspects that need to be considered as well. Many patients, when given a certain kind of pain killer drugs, may develop tolerance and addiction to the drugs.

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Again, there may be patients who may be addicts, and present themselves deliberately to get their “dose” of the drugs. The recognition of patients who may be developing addiction, or are using hospital as a source of addiction is very important which may require certain corrective and legal measures. Therefore, the administration of painkiller drugs also holds a certain amount of legal perspective as well. Apart from the use of such painkillers, there are many studies and researches that point to the role of various psychotropic drugs in the management of pain.

While the association may seem sparse on the up front, patients with pain are frequently agitated and worried, and may require some “calming of the nerves”. In such patients the use of psychotropic and anti anxiety drugs is considered a good option. There are many researches that now support this theory, and claim that an emergency setting can respond better with appropriate use of these drugs. It is however important to take into consideration the type of pain for which the patient presents with.

While acute pain patients may not have a large chance of developing a dependence on the drugs, it is the chronically ill patients that are of more concern. Patients of cancer and arthritis etc. are prescribed with chronic pain medication in accordance with the severity of the pain. Most of these patients are given prescriptions, which may not be maintained or fully monitored. While in the hospital admitted cases, the identification of addiction and dependence patterns can be easily diagnosed and dealt with, the same is not true for patients who are living in homes and receiving their medications their.

To address this problem the government again introduced various measures to help control the dispensing of such drugs, and periodic evaluation of such patients at outpatient settings. The administration of pain killer drugs is a measure as well as responsibility of the health care provider. Pain is defined as “an unpleasant sensory and emotional experience associated with actual and potential tissue damage or described in terms of such damage” (Zempsky and Schenchter, 2003) Many physicians feel that pain in the emergency rooms is not treated very well.

Studies have shown that pain is the most common presenting complaint in the emergency department, yet is not so commonly handled or managed. (Sorelle, 2002) Researchers in studies have shown that many times the patients are given the pain medication very late or not at all. However, there are many factors that complicate the situation as simply patient comes, patient receives, and patient leaves. The time it may take for various preliminaries, the history taking and the final decision about whether the patient does need medication are among the various factors that can affect prompt medicine giving.

The studies have pointed out the lack of information and lack of management of pain in the systematic manner. These studies therefore point out to the need of a good method of understanding and relieving pain. (Sorelle, 2002) Current pain management strategies recommended include the following:

• Introduction of low doses of drugs initially and gradually increase to reach the optimum effect for the patient’s pain relief.
• Combined drug therapy. This helps in reducing the doses of the drugs, and thereby prevents side effects of one drug
• Continuous analgesia, which is now being used widely in emergency settings.
• Use of behavioral methods along side pharmacological interventions to increase response. (Feinberg, 2004)

Centrally acting opioids analgesics are used widely for the remedy of pain in the clinical settings. Tramadol is among the new line of opioids narcotic agents that are used for moderate to severe pain. It acts both as a weak opioids agonist and as an inhibitor of monoamine neurotransmitter reuptake.

Both oral and parenteral forms have shown good results in the management of pain. (Scott and Perry, 2000) The advantage of this drug is that there is less dependence to this drug than other opioids. It does not affect the respiratory rate, and has lesser irritation effect on the GIT than other drugs. It also has a lesser risk of seizure than other drugs. (Feinberg, 2004) The second most common line of drugs used in this group of medication is the COX 2 inhibitor drugs.

These drugs have shown at least similar efficacy in the management of pain when compared to COX non specific drugs. Parecoxib sodium for example, has similar effects to non specific nsaids in the injectable form. These drugs have shown a superior activity to morphine for most measures of analgesic efficacy, and have a prolonged duration of action. (Scott et al,2002)  Many researches are now questioning the value of the visual analog scales used widely to monitor the level of pain.

Bodian et al, (2001) carried out a research to identify the relation between the changes of analgesic intravenous doses with the documentation on the VAS charts by the patients. The study also aimed to find out if watching previous VAS scores by the same patient had any influence on the later scoring of the pain. Bodian was able to conclude that “when pain is an outcome measure in research studies, grouping final VAS scores into a small number of categories provides greater clinical relevance for comparisons than using a full spectrum of measured values or changes in value.

Seeing an earlier VAS form has no apparent influence on the later values. ” (Bodian et al, 2001) Pain management in children especially neonatal kids was not much debated until in the recent years. However, there are many recent methods that are used to alleviate pain in the recent pediatric settings. These include prevention of pain, where the pain is treated prophylactically. The identification and proper assessment of the pain is another crucial element in the pain management in children.

The treatment of pain while initially considered to be limited to only providing analgesics, has recently evolved to include physical methods such as massages, transcutaneous electrical nerve stimulation, and behavioral methods such as hypnosis, distraction, preparation and rehearsal. (Zempsky and Schechter, 2003) Current child pain management heavily relies on the information received from the parents, and uses them during the pain procedures as a source of comfort to the child.

The introduction of painless analgesia technique is another method of inducing cooperation from the patient. And reduction of anxiety, a very important feature in a child is another very important area in the management of pain. (Zempsky and Schechter, 2003) Benzodiazepines are used very widely as sedatives in children with successful results. However, the only problem associated with it is the development of tolerance to it. In such children withdrawal symptoms cause severe distress and the child may express irritability, ataxia, aggression, hallucinations, and twitching.

Other symptoms include inconsolable crying, agitation, vomiting, anxiety, hyperactivity, convulsions, tremors, jitterness, poor feeding gagging. The form used in children is midazolam, and is used for a variety of purposes. Their indications include sedation, amnesia, anticonvulsant, and anesthesia. (Bennett, 2001) If benzodiazepines are given to such children for more than 3 days, then these should be weaned off slowly. If the child exhibits withdrawal symptoms, then diazepam, a less intensive benzodiazepine can be given until the effect wears off.

(Bennett, 2001) The pain scales used in children include the Oucher Scale, Faces Scale, Poker Chip Tool, Colored Analogue Scale, the Pain Thermometer, Visual Analogue Scale, and the McGill Pain Questionnaire respectively. The most common drugs used in pediatrics include opioids and NSAIDS. Included in the pain management techniques are behavioral approaches such as distraction etc. The current evaluation scales have improved considerably since the last two years, and have improved the outcomes of the pediatric pain management as well.

With increased understanding about the various modalities of pain, there are now novel and newer methods introduced in medicine to reduce pain in patients. The use of adjuvant drugs is used to enhance the efficacy of the analgesia and to improve the tolerance to pain. Drugs such as antidepressants, antihypertensives, local anesthetics, and CNS stimulants are widely used as adjuvants to control analgesia and to improve patients’ experience of pain.

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