Why is Pain Still Under-Treated in the Emergency Department? Two New Hypotheses.

Across the world, pain is under-treated in emergency departments (EDs). We canvass the literature testifying to this problem, the reasons why this problem is so important, and then some of the main hypotheses that have been advanced in explanation of the problem. We then argue for the plausibility of two new hypotheses: pain's under-treatment in the ED is due partly to (1) an epistemic preference for signs over symptoms on the part of some practitioners, and (2) some ED practices that themselves worsen pain by increasing patients' anxiety and fear. Our argument includes the following logic. Some ED practitioners depart from formal guidance in basing their acute pain assessments on observable features rather than on patient reports of pain. This is potentially due to an epistemic preference for signs over symptoms which aims to circumvent intentional and/or unintentional misrepresentation on the part of patients. However, conducting pain assessments in line with this epistemic preference contributes to the under-treatment of pain in at least three respects, which we detail. Moreover, it may do little to help the practitioner circumvent any intentional misrepresentation on the part of the patient, as we explain. Second, we examine at least four ED practices that may be contributing to the under-treatment of pain by increasing patient anxiety and fear, which can worsen pain. These practices include failing to provide orienting information and partially objectifying patients so as to problem-solve along lines pre-established by modern medical science. We conclude by touching on some potential solutions for ED practice.

Harm reduction and HIV-prevention among injecting drug users in Australia: an international comparison.

In response to the threat of HIV transmission via drug injection with shared needles, Australia developed a needle and syringe exchange program that became one of the most comprehensive in the world. Originally health professionals and pharmacists were given the responsibility of implementing the program. However, community-based AIDS organizations were soon also funded to distribute sterile injecting equipment, alcohol swabs, puncture-proof disposable containers, condoms, and safe sex information. Nearly all of the programs operated on a no-need-for-exchange basis, during hours and from outlets (both fixed and mobile) that were convenient for users. Their success in preventing the widespread transmission of HIV among injecting drug users was demonstrated in international studies that found a large discrepancy between the rates of HIV infection in cities with, and without, needle and syringe exchange programs, and was reflected in the continued low level of HIV infection among injecting drug users in Australia. Australia's success in preventing HIV transmission among drug users suggests the merits of the "harm reduction" approach to controlling drug use as well as funding community-based needle and syringe exchange programs.