Pain scores among ED patients: correlation with
desire for pain medication
Catherine A. Marco ∗ †‡, Megan McGervey † , Joan Gekonde † , and Caitlin Martin †

†University of Toledo Health Science Campus, Toledo, OH 43614, and ∗Wright State University, Dayton, OH 45435

Introduction: Pain has been identified as the most common rea-
son for Emergency Department (ED) visits. The verbal numeric
rating pain scale (VNRS) is commonly used to assess pain in the
ED. This study was undertaken to determine whether VNRS pain
scores correlate with desire for pain medication among ED pa-
tients.
Methods: In this prospective survey study, eligible patients in-
cluded Emergency Department patients over 18 with painful con-
ditions. The primary outcome measures included self-reported
VNRS, ED diagnosis, number of ED visits and number of ED ad-
missions within the past year, and the self-reported desire for pain
medication.
Results: Among 482 participants in 2012, the median triage pain
score was 8 (IQR 6-10); the most frequently occurring score was
10. Overall, there were significant differences in pain scores with
patient desire for analgesics. 67% reported desire for pain med-
ications. Patients who did not want pain medications had signif-
icantly lower pain scores (median 6; IQR 4-8) compared to those
who wanted medication (median 8; IQR 7-10) (p<0.001) and com-
pared to those who were ambivalent about medication (median 7;
IQR 6-10) (p=0.01). There was no association between desire for
pain medication and demographics including age, gender, race,
or insurance status.
Conclusions: ED patients who did not desire pain medication had
significantly lower pain scores than patients who desired pain
medication. Pain scores usually effectively predicted which pa-
tients desired pain medications. Desire for pain medication was
not associated with age, gender, race, or insurance status.

pain | emergency | pain assessment

Treatment for pain and related conditions has been identified asthe most common reason for Emergency Department (ED) visits
(1). Pain is estimated to cost $560 to $635 billion dollars per year in
America (2). Effective pain management results in improved patient
satisfaction, reduced anxiety, and improved comfort.(3] However, de-
spite widespread consensus that pain relief should be one of the pri-
orities of the medical profession, numerous studies have documented
inadequate pain management in ED patients (4,5,6).

The verbal numeric rating scale (VNRS) is commonly used to
assess pain by self-report in Emergency Departments. The VNRS
asks for a patient self report of pain on a scale of 0-10, where 0 is
“no pain” and 10 is “worst pain imaginable”. Previous studies have
demonstrated that both VNRS and visual analog scales (VAS) are
valid methods of measurement of self-reported pain (7,8,9).

ED patients report variable levels of pain, even with similar types
of diagnoses or injuries (10).

This prospective survey study was undertaken to identify pain
scores among ED patients with painful conditions, and identify asso-
ciation with desire for pain medication.

Materials and Methods
Study Design. This prospective observational survey study was con-
ducted at the University of Toledo Medical Center ED, an urban, uni-
versity hospital with an annual census of 34,000. The study was ap-
proved by the University of Toledo Institutional Review Board. Data
were collected prospectively from the ED electronic medical records
and from patient surveys during May - July 2012. Eligible partici-
pants included ED patients over 18 years of age with painful condi-
tions ranging from 1-10 on the VNRS scale.

Patient Selection and Data Collection. Participants were identified
and invited to participate as a convenience sample when a research as-
sistant was available. Eligible participants were identified based their
self-reported triage VNRS ranging from 1-10 on the VNRS scale.
Patients who rated pain as 0 were not included. For patients who
had multiple visits during the period of this study, only data from the
initial visit was recorded.

Outcome Measures. Patients were asked to consent to completing a
written survey (Appendix A). This survey included questions on de-
mographics including age, sex, race, insurance status. The number of
University of Toledo ED visits and admissions within the past year
was extracted by research assistants from the medical record. The pa-
tient’s triage pain score and final ED diagnosis were noted. Finally,
patients responded to whether or not they desired pain medication
during their current visit along with commets as to why or why not.
For participants not capable of making medical decisions, the power
of attorney (POA) or the primary care-taker was asked to complete
the survey.

The patient’s initial triage pain score was obtained from the med-
ical record. If they met the requirements for selection (a pain score
ranging from 1-10 on the VNRS scale), the patient was invited to par-
ticipate, and a research assistant compiled the patient’s responses to
the survey. Research assistants were made available during a variety
of hours to obtain a range of responses to reach a broad demographic
population. Diagnoses were coded into one of 19 categories, based on
a previous diagnostic reporting method (11) Patient responses were
collected and data was categorized to determine if there was any cor-
relation between the perceived pain as measured by the verbal nu-
merical rating scale and the patient’s demographics.

Statistical Analysis. Descriptive statistics are provided for all 482
patients using frequency and percent, or median, interquartile range
and mode. Differences in triage pain scores by patient’s desire for
medication was tested overall (yes, no, undecided) using a Kruskal
Wallis two-tailed test. Comparisons between patients desiring med-
ication or not were tested using Wilcoxon two-tailed tests. (The 15
patients who responded neither yes or no were eliminated from the
sub-group analyses due to small sample size). The 6 patients with
“other” insurance were not included in the analysis of insurance be-
cause their group was small. Associations between desire for pain
medication and demographic characteristics were tested using Chi-
square tests. P values <0.05 were determined to be statistically sig-
nificant. Data were analyzed using SAS v 9.1. (Statistical Analysis
Software, Cary NC v 9.1).

‡To whom correspondence should be sent: Catherine.Marco@wright.edu

Author contributions: CAM designed the research protocol; CAM, MM, JG and CM collected
study data; CAM supervised the data analysis; all authors contributed to the manuscript and
CAM takes responsibility for the paper as a whole

The authors declare no conflict of interest

Freely available online through the UTJMS open access option

utdr.utoledo.edu/translation/ UTJMS 2014 Vol. 1 No. 1 1–3



Results
A total of 482 patients were enrolled in the study between May

and July 2012. Participants included 62% females and 38% males.
The median age was 40 (IQR 28 - 55). Ethnicity included Cau-
casians (58%; n=278), African American (37%; n=176), Hispanic
(4%), Asian (1%), and Multiracial, other, or unknown (1). Insurance
status included four categories: Self-pay (21%), Government (33%),
Private (44%), or Other (1%). The majority of patients had not been
hospitalized at UTMC in the past year, and the median visits to the
UTMC Emergency Department within a year from the survey was 1
(IQR 0-2).

The median VNRS pain score was 8 (IQR 6-10). The mode pain
score was 10. Overall, 67% of patients surveyed desired pain medica-
tion (n=323). 30% of patients did not want pain medications (n=141)
and 3% of patients did not express a desire nor deny a desire for pain
medications (n=15).

The Primary ED Diagnosis was categorized into 14 categories.
Categories with the most study participants included “Abdominal
pain/GI/Pelvic causes” with 18% of all participants, and “Chest pain
equivalents” with 11% of participants.

Table 1. Primary Diagnosis Among 482 Study Participants

Primary Diagnosis N (%)

Abdominal pain/ GI/ pelvic 87 (18%)
Chest pain 55 (11%)
Traumatic skin/soft tissue 48 (10%)
Musculoskeletal/extremity pain 47 (10%)
Sprain/strain/spasm 40 (8%)
Respiratory infection 30 (6%)
Back/neck pain 29 (6%)
Headache/migraine/concussion 29 (6%)
Toothache 25 (5%)
Fracture/dislocation 21 (4%)
UTI/STI/vaginosis 14 (3%)
Abscess/cellulitis/rash 8 (2%)
Renal colic/flank pain 7 (1%)
Other 41 (9%)
Missing 1 (0%)

Overall, there were significant differences in triage pain scores
with patient desire for pain medication (Kruskal Wallis p<0.001).
Comparing groups two-at-a-time, patients who did not want pain
medication had significantly lower pain scores (median score 6) com-
pared to those who expressed desire for pain medication (median
score 8, Wilcoxon p<0.001) and compared to those who were un-
decided about pain medication (median score 7, Wilcoxon p=0.01).
There was not a significant difference in pain scores between pa-
tients who desired pain medication and those who were undecided
(Wilcoxon p=0.2; Table 2).

There was not enough evidence to support an association be-
tween patient desire for pain medications and age, gender, race,
nor insurance status (Table 3). Due to small numbers in individual
groups, statistical testing was not performed on diagnoses and asso-
ciated with desire for pain medication.

The diagnoses with the highest percentage of patients desiring
pain medications were back/neck pain (93% reported a desire for
pain medications), fracture/dislocation (86%), and renal colic/flank
pain (86%). Diagnoses with the lowest percentage of patients desir-
ing pain medications were chest pain (52%), abscess/cellulitis/rash
(52%), and UTI/STD/bacterial vaginosis (57%; Table 3).

Table 2. Differences in triage pain score between patient desire for
pain medications

N
Median

[interquartile
range]

Mode

Patient wants
pain

medications
323 8 [7, 10] 10

Patient doesn’t
want pain

medication
144 6 [4, 8] 6

Patient did not
answer either

yes or no
15 7 [6, 10] 10

Table 3. Association between Desire for Pain Medication and Patient
Demographics

Would you like pain
medication in the ED

today?

No Yes
Chi-

square
P-value

Age 0.08
<60 112 (78%) 273 (85%)
>60 32 (22%) 50 (15%)

Gender 0.30
Male 50 (35%) 128 (40%)
Female 94 (65%) 194 (60%)

Race 0.38
African American 52 (36%) 119 (37%)
Caucasian 87 (60%) 182 (57%)
Other 5 (3%) 21 (7%)

Insurance 0.06
Self-pay 27 (20%) 71 (22%)
Private 74 (53%) 134 (42%)
Government 38 (27%) 117 (36%)

Primary Diagnosis 1

1 traumatic skin/soft tissue 18 (13%) 30 (9%)
2 sprain/strain/spasm 9 (6%) 30 (9%)
3 back/neck pain 2 (1%) 25 (8%)
4 abdmoninal pain/ GI/ pelvic 21 (15%) 59 (18%)
5 fracture/dislocation 3 (2%) 18 (6%)
6 headache/migraine/concussion 5 (3%) 25 (8%)
7 chest pain 25 (17%) 27 (8%)
8 respiratory infection 2 (1%) 6 (2%)
9 abscess/cellulitus/rash 12 (8%) 13 (4%)
10 toothache 5 (3%) 24 (7%)
11 uti/std/bacterial vaginosis 6 (4%) 8 (2%)
12 renal colic/flank pain 1 (1%) 6 (2%)
13 musculoskeletal/extremity pain 12 (8%) 34 (11%)
14 other 23 (16%) 17 (5%)

1No statistical testing

2 utdr.utoledo.edu/translation/ Marco et al.



Discussion
Pain management is an important and challenging task in emer-

gency medicine. Despite widespread educational initiatives regard-
ing pain management, oligoanalgesia among ED patients remains a
common issue (12,13). Thirty to 60% of patients complaining of pain
do not receive any treatment for pain while in the Emergency Depart-
ment (14). Oligoanalgesia has been attributed to several causes. The
main attribution since the term was coined by Wilson and Pendleton
in 1989 has been physician bias and disbelief or belief of exaggera-
tion of pain reporting due to racial and ethnic factors (15).

Accurate assessment of pain can be an important step in adequate
pain management (16). Self-reported pain scores are considered the
standard of choice in assessing pain. The VNRS is commonly used
to assess pain. Other pain scales may also be used, including the
Visual Analog Scale (VAS), Verbal Descriptor Scale (VDS), and the
Wong-Baker Faces Pain Scale. Previous studies have demonstrated
that patients’ self reported pain is highly variable (17). Marco et al
showed that ED patients rate pain on the VNRS based on current
subjective pain, or by comparison to previous or hypothetical pain
experiences (18).

Although the VAS and VNRS are well correlated, patients sys-
tematically score their pain higher on the VNRS, with an unaccept-
ably wide distribution of the differences (19). The authors also note
several important advantages of the VNRS, including ease of use and
no requirement for motor skills or instruments. To improve and stan-
dardize ED pain care, multi-center prospective studies are needed to
validate the widely variable disparities of pain management based
on patient and physician characteristics; and examine knowledge and
attitude development about pain and its management (20).

Other ED issues contribute to the challenge of appropriate and
adequate pain management, including acuity and triage issues and
disparities in pain assessment and management. Several studies have
identified racial and gender disparities in ED analgesia administration
(21,22). Another study identified practice variation to be affected by

age, race, and type of pain and the physician’s identity, and training
(23). Age also plays into the disparities seen in pain assessment. A
recent study demonstrated that patients aged 75 years and older with
pain-related ED visits were less likely to receive an analgesic pain
medication in the ED, compared to patients aged 35 to 54 years (24).

Despite these numerous studies citing disparities in ED adminis-
tration, our study did not identify differences in desire for pain med-
ication by gender, age, or ethnicity. One explanation is that although
no difference exists for desire for pain medication, there may be dis-
parities in the delivery of analgesia by demographic characteristics.

To improve patient care, guidelines and treatment principles
have been developed and adapted by several national societies (25).
Changing the attitudes of emergency medical providers about pain
assessment and management will require attention in several areas of
research, education, and training (26).

Study Limitations. This study was conducted at a single urban aca-
demic hospital, and results may not be generalizable to all ED pa-
tients. Data were only collected during the summer months between
May and July; therefore, results only represent a few months of the
year. The survey results were based on patients’ self-reported pain
scores as well as patients’ self-reported desire for pain medication.
Both of these assessments are highly subjective measures that are apt
to change depending on several confounding factors. To assess de-
sire for pain medication a single, open-ended question was asked.
"Pain medication" was also not defined for patients, thus results may
have been skewed by differences in how each participant defined pain
medication.

Conclusions. ED patients who did not desire pain medication had
significantly lower pain scores than patients who desired pain medi-
cation. Desire for pain medication was not associated with age, gen-
der, race, or insurance status. The question, "Would you like pain
medication in the ED today?" is a feasible and effective question to
guide pain management in the ED setting.

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ACKNOWLEDGMENTS. The authors would like to acknowledge Nancy Buderer,
MS, for her statistical expertise with the data analysis for this project.

Marco et al. UTJMS 2014 Vol. 1 No. 1 3