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Take on the issue of chronic pain with comprehensive solutions, firm policies on prescribing
EDs curb drug-seeking behavior while guiding patients to more appropriate resources
It's a problem that every ED grapples with: A patient comes in complaining of chronic pain and you give him or her a one-time prescription for a powerful narcotic with instructions to seek comprehensive treatment from a primary care provider (PCP). But the patient keeps coming back to the ED sometimes as frequently as once or twice a week. And there is often no telling what other EDs or providers the patient has visited for pain medications in the mean time.
How to best meet this patient's needs can present a real quandary for emergency medicine personnel. "The issue has been put in somewhat higher relief as we have seen increases in prescription drug misuse and abuse over the last decade," explains Knox Todd, MD, MPH, chairman of the Department of Emergency Medicine at the University of Texas MD Anderson Cancer Center in Houston, TX. "And that is in the face of what many consider to be an unmet need among patients with under-treated pain." (Also, see "Patents seeking pain meds: Appearances can be misleading," below.)
Patients who come to the ED seeking narcotic medications do not necessarily represent a huge number, but they can consume an enormous amount of time and resources, explains Suzanne Johnson, DO, FACEP, assistant director of the ED at Alameda Hospital in Alameda, CA, and the chief medical officer of Rational Pain Care, an Oakland, CA-based organization that helps hospitals and EDs devise solutions for dealing with chronic pain in emergency settings.
"These are patients who have a difficult time managing chronic pain in the outpatient setting, so they are really using the ED inappropriately to obtain short-acting narcotics, as well as narcotic prescriptions," says Johnson. "And because these folks often have overlaying psychosocial issues that make dealing with their chronic pain more difficult for them, they can present significant behavioral challenges to us in the ED."
While many EDs have responded to the problem by implementing "no-opioid" policies for patients who visit the ED frequently, this approach rarely works, says Todd. "Those fairly simplistic rules tend to break down pretty quickly. Most EDs that have tried to implement a no-opioid policy have quickly violated that policy, and do so routinely. It doesn't have a lot of lasting value."
However, while there may be no simple solutions to the problem, some EDs are making progress with more robust solutions that connect patients with resources, set up means of communications between providers, and establish clear prescribing policies that all emergency providers follow.
View ED visit as an opportunity
Charles Shufflebarger, MD, chair of emergency medicine at Clarion Health in Indianapolis, IN, has observed an increasing number of patients with chronic pain in the ED over the last several years. "I have responsibility for several EDs, and it is the same pattern in all of them," he says. But just this past October, Shufflebarger and colleagues at Methodist Hospital in Indianapolis began an innovative program aimed at connecting these patients with resources that will help them manage their pain without repeated trips to the ED for medications.
"We worked with our behavioral-health and our care-management staff to develop a multidisciplinary approach so that when patients are identified who have chronic pain, and who have not been on a chronic pain treatment program, we are able to get our care-management staff to coordinate care with their PCPs, as well as our chemical dependency staff," explains Shufflebarger. "We don't deny treatment for pain initially. What we do is use the visit in which we identify the need as an opportunity to give the patient information about our program, and to let them know how strongly we feel it is important for them to follow-up through it."
When a patient with chronic pain first presents to the ED for care, it is the treating physician's job to explain the program and why it would be beneficial. Care-management nurses reinforce this message and provide printed materials that describe the program, explains Shufflebarger. When patients don't have a PCP, the ED staff will find them one and get an appointment set up. "We make sure that the PCP is aware that we are also making a referral to a dependency program for pain management," says Shufflebarger. "Our dependency program provider has agreed to see all of these patients without regard to their insurance or any other considerations."
Care managers will notify the chemical dependency provider when a patient has been referred, and the chemical dependency provider will let the ED know if that patient has failed to schedule a follow-up appointment, says Shufflebarger, noting that patients are given a window of time to connect with both the PCP and the chemical dependency provider. "If patients haven't followed up, usually within about two weeks, then we are disappointed that they haven't followed through with our referrals and we consider them to be out of compliance with what we require," he says. "Most of those patients will not be treated with controlled substances in the future."
Get all providers in the loop
A key aspect of the program is that all the providers involved with the program have access to care-management notes that are available through the health system's electronic medical record. "Everyone internally has access, and most of the doctors who are in our system have access to these notes as well," says Shufflebarger. As a result, the care-management notes become a central means of communication, keeping PCPs, ED clinicians, and the chemical dependency provider informed about a patient's progress with the treatment plan.
Just eight months into the program, it is too early to quantify the results, but Shufflebarger says the program has produced moderate success. "We have examples of patients who are doing well in the dependency program, we have patients who have graduated from the program and are now on pain management without narcotics, and we have many patients who have failed," he says. "We didn't expect that this would be successful for a huge majority of patients."
However, Shufflebarger says program administrators are pleased with the approach because it provides a good opportunity for patients who are open to treatment for their chronic pain to get into a better care plan. "It is true that this is a difficult ailment to treat, but some patients will get better, so if our only approach is 'you can't get your medicines here' we might be missing an opportunity into a better way of treating their pain."
Develop a policy
The ED at Dosher Memorial Hospital in Southport, NC, has also experienced frustration from patients coming in regularly to seek treatment for chronic pain. In fact, as recently as two years ago, it became clear that something needed to be done to address the problem, explains JoAnn Turzer-Commesso, RN, the director of emergency services at Dosher. "We kept telling these patients that they needed to go to their PCP for treatment of pain, but it didn't seem to be getting through," she says. "We had some patients coming in here more than 30 times a year, and there were quite a few coming in once or twice a month."
It got to the point where the medical executive committee at the hospital asked ED leaders to investigate the problem and come up with a policy to manage the issue, says Turzer-Commesso, noting that it took six months of regular meetings between ED department leaders and hospital medical executives, and input from risk management, to come up with a working policy.
"We had very long discussions, and we reviewed policies from other hospitals," adds Turzer-Commesso. "The other issue was there had been some deaths in the community related to drugs, so the medical examiner was able to give us some information as well."
The new policy, which was implemented in January of 2010, establishes that the ED physician will determine whether a patient complaining of pain will be treated with narcotics, but it also states that patients with chronic pain should be treated by their PCP, explains Turzer-Commesso. "In most cases, physicians will give these patients non-narcotic medications to treat their pain, and we will refer them back to their PCP," she says. "We also refer some patients to pain clinics, we talk to them about their pain management, and we document this in their chart."
Get physician input
For cases in which patients do not have a PCP, the ED staff will try to connect them with a provider or a health clinic in the area. "We look at each patient individually. If we have a patient who keeps coming back, the physicians look the patient up in a North Carolina registry to see if she or he has been to other places," she says.
When the policy was first implemented, the hospital made sure that it was publicized through local media so that community residents would be aware of the change. In addition, the policy is posted so that patients coming into the ED have an opportunity to review it. As a result, most patients have been cooperative, and the ED is not as backlogged as it used to be, says Turzer-Commesso.
Volume is slightly down in the ED, although Turzer-Commesso says it is not clear whether the change has to do with the new policy or some other factor. However, she stresses that much of the drug-seeking behavior has stopped, and many patients who have been referred to pain clinics or other providers for help are making progress. "We know quite a few patients who have come clean," she says.
Furthermore, the ED physicians who had ample opportunity to review the policy and offer their input have reported no difficulties in working under the new guidelines. "At least they have something to lean back on now," says Turzer-Commesso. "They can [tell patients] that we have this policy."
Patients seeking pain meds: Appearances can be misleading
The majority of patients in the ED are dealing with some type of pain, and for many of these patients, the pain doesn't go away in a week or a month, explains Knox Todd, MD, MPH, chairman of the Department of Emergency Medicine at the University of Texas MD Anderson Cancer Center in Houston, TX. "As many as 25% or 30% of patients have underlying chronic or recurring pain. That is 24 million patients a year in the United States," he says.
However, best meeting the needs of these patients has always been a question of balance and risk assessment, says Todd. "How do we balance what we know are the efficacious effects of opioids in treating pain and also look at aberrant drug-related behavior and assess the risk for misuse?" he says.
The role of EDs in contributing to the over-prescription of opioids has been overstated by many databases because they don't take into account the fact that most prescriptions written be emergency providers are for small amounts that cannot be refilled, says Todd. "I have seen some national statistics that put us rather high on the list based probably on single prescription writing, but rather low on the list if you look at the total amount that is prescribed."
Furthermore, Todd says that emergency department personnel tend to magnify the impact of some patients and categorize them inappropriately. For example, when Todd was a resident, he recalls that there were two patients with sickle cell disease who presented frequently to the ED with pain: an older African-American female and a young African-American male. When the chair of the department asked the staff which patient came in more frequently for pain medication, everyone indicated that it was the young man. "He tended to be more hostile when he came in, so there was more controversy surrounding his visit," says Todd. "But when we actually went back and looked at the data, the older woman was in the ED three times as often as the young man ... so it is easy to over-estimate the contributions of a small number of individuals."
Nonetheless, given the complexity involved with appropriately managing patients with pain, Todd observes that an increasing number of emergency physicians are seeking added training in pain medicine. "I think we are going to see more emergency physicians pursue post-residency training in a subspecialty of pain medicine and apply that back to the ED, or perhaps become pain physicians," says Todd. "That might be a natural outgrowth of our specialty."
In recognition of this trend, the MD Anderson Cancer Center is establishing an oncologic emergency medicine fellowship with a focus on pain medicine. "We want to be the first emergency fellowship program in the country that offers training in pain medicine," says Todd.