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Although supported by both ethical and pragmatic imperatives, pain treatment faces significant barriers, particularly in the setting of emergency medicine. This article argues that pain management is integral to good patient care and specifically, good emergency care. In order to achieve effective emergency pain management, it is crucial to understand the "root causes" of pain neglect in emergency medicine - i.e. to understand why emergency physicians behave as they do in pain treatment.

This article begins by addressing the neglect of pain in emergency medicine and the dearth of empirical research regarding the causes of this neglect. After considering barriers to effective pain management that pervade many areas of medical practice, it considers distinctive reasons for undertreatement of pain in emergency departments. These include subordination of pain relief to diagnosis in the ED; the inadequacy of pain assessment techniques; and the stressful ED environment in which unfamiliarity, detachment, and alienation function highly in the doctor-patient relationship.

The article then considers legal barriers to effective ED pain management. Fear of malpractice litigation regarding the use of pain medications can translate into undertreatment of pain, but this article points out that such undertreatment - including discontinuity of care at discharge and the neglect of palliative care for the terminally ill - can actually subject physicians to greater legal risk. Informed consent is another factor that affects ED pain management; the inability to obtain informed consent, the concern that opioids will disable patients from consenting to further treatment, and the worry that pain treatment will affect patient behavior post-discharge all factor into ED pain treatment decisions. Finally, limitations inherent in the policies of the ED affect pain treatment when certain emergency clinicians are restricted from treating patients.

The article concludes by considering the federal Emergency Medical Treatment and Labor Act and the relationship between federal and state regulation of prescribing practices. It argues that the EMTALA should incorporate a clear duty to provide emergency pain management as an essential part of its stabilization requirement. Finally, the article addresses "balance" as an important regulatory and clinical goal when dealing with competing issues of diverting misuse of controlled substances and prompting effective relief of pain.