P AIN , P RIORITIES, AND P REHOSPITAL C ARE

reason for patients to seek emergency care, and annually accounts for approximately $100 billion in direct medical costs and lost productivity in the United States. Given these staggering statistics, it should follow that emergency care providers are proficient in providing effective pain management. Unfortunately, this is not the case. Several emergency department (ED) studies have shown insufficient treatment of pain in ED patients, from lack of analgesic administration,1–3 excessive delays in administration,1,4 underestimation of pain,5,6 and inadequate dosing of analgesic agents.4,7 Patients most at risk for not receiving analgesics are children,2,8 the elderly,9 and African American and Hispanic patients.10,11 This phenomenon, termed “oligoanalgesia,” has been pervasive and has its roots in medical training of physicians, nurses, ancillary staff, and out-ofhospital providers. Why are we so stingy? The assessment and management of pain are often inadequate since many practitioners have had little to no formal training in pain management. Many have learned behaviors in managing pain from copying the habits of their predecessors, who may have likewise poorly understood the appropriate management of pain. Medical training emphasizes searching for a diagnosis and instituting diagnosis-specific treatment, not managing symptoms while the search for a diagnosis is made. Many fear that relieving pain while searching for a diagnosis will mask the ability to make the diagnosis, despite any evidence to support this phenomenon. Studies have demonstrated that physicians and nurses typically underestimate the amount of pain experienced by patients,5,6,12,13 and by the sheer nature of working with patients in pain become desensitized to the suffering that patients endure. Many have seen and treated those with abuse problems and consequently are irrationally concerned about abuse and addiction to opioid analgesics in all patients suffering from acute pain.14 Many fear government retaliation for the use of opioid analgesics for acute pain, despite that regulatory agencies do not discipline practitioners for appropriate use of opioid medications for pain. In this issue of Prehospital Emergency Care, McLean et al.15 estimate that a minimum of 4.9 million patients transported to hospitals via ambulance in 1999 were suffering from pain. They appropriately state that this is a conservative estimate since opioid analgesics were also administered to an additional 13% of 7.6 million patients in whom no pain was reported, accounting for nearly an additional 1 million patients. Additionally, since pain was not recorded until the time of ED arrival, emergency medical services (EMS) interventions to relieve pain could have resulted in underreporting. Since this estimate does not include patients in whom analgesic administration was withheld or refused, the number of patients transported suffering from acute pain is undoubtedly higher. What impact could we have made in the field on these 6 million patients who accounted for a considerable proportion of all ED visits in 1999? Since analgesics were given to only 21% of those in whom moderate to severe pain was recorded, this would indicate that oligoanalgesia is at least as prevalent in the out-ofhospital environment as well as within the hospital. While we may be very effective in treating chest pain due to coronary ischemia in the field, how effective are we in treating other types of pain? McEachin et al.16 reported that only a minority (18.3%) of adult patients transported by EMS to their hospital over a four-month period with lower-extremity or hip fractures received any prehospital analgesics, although most did receive analgesia in the ED. Considering that multiple trauma patients were excluded, it would appear that the majority of these patients could have benefited from prehospital analgesia. Their results also suggest that older patients PAIN, PRIORITIES, AND PREHOSPITAL CARE