“Red Flags” in the Emergency Department: Pain Treatment vs. the Painful Epidemic of Addiction May 1, 2012 Physician Resource, San Francisco Medicine, SFMS Member addiction medicine, opioid, pain treatment 0 The New York Times today reported on the difficulty of sorting out legitimate pain from drug-seekers in emergency settings. SFMS board member Keith Loring, MD and staffer Steve Heilig wrote about this—with practical tips—in the April issue of San Francisco Medicine. Every emergency clinician knows them, and most learn to dread them—the patients who might be “drug-seekers” or might be in real physical pain—or might be both. How to screen the addicts from the "legitimate" pain patients? Faced with these and a multitude of other patients for whom pain is the chief complaint, objectivity and consistency in approach are paramount. A quick set of questions is generally sufficient to devise an appropriate diagnostic and treatment plan that minimizes overprescription of narcotics, adequately treats patients with real pain, and helps identify patients for whom the disease of addiction should be considered and addressed: Is the pain new or long-standing? Is the pain associated with an obvious or clinically identifiable physical abnormality or disease process? Is the pain being treated on an outpatient basis and if so, by whom? What medications, if any, has the patient used to treat the pain? The answers place patients in one of four categories: Acute pain associated with an obvious medical or surgical cause. This category of patients is straightforward and the major focus on their pain should be to achieve adequate relief with whatever medication is necessary. Acute pain with no clear or objectively identifiable physical abnormality or disease process. This category of patients is the most likely to include the drug-seeker or addict who is wise to the system and is even willing to undergo an involved workup in order to obtain opiate pain medication. These patients will go from hospital to hospital in hopes of staying under the radar. A clinician has to be willing to research the patient’s visit history at their own and other emergency departments in order to begin to address the possibility of drug-seeking in the patient. This is also where a program such as CURES in California can be helpful. Chronic pain that is untreated. This group of patients is easy to identify and very difficult to manage. Chronic pain is complex, often requiring treatment by a specialist. These patients need to establish care with a pain specialist but often will not or cannot. They return to the ED for pain control, get variable treatment each time, and create increasing frustration for everybody. The pattern can be broken, but this requires coordination and agreement among ED staff to ultimately be willing to withhold pain medication. For this to occur, patients need to be informed in writing in their discharge instructions and it must be documented in their ED record that they will no longer be given narcotic medications in the ED without the approval of a primary physician or pain management specialist. Chronic pain that is being treated. Once identified, these patients should never be given pain medication unless approved by their own physician. Patients with chronic pain who are under treatment by a pain specialist generally contract that they are never to go to the ED for pain treatment. Some still try, in hopes that the ED is too busy to contact their physician. But for the emergency physician, that is always a call worth making. No matter which category of patient, the disease of addiction can be present. Sensitivity to this possibility is crucial; saying nothing only contributes to a patient’s willingness to remain in denial of their problem. This is an excerpt from the featured article in the April 2012 issue of San Francisco Medicine on Pain Management. Click here to view the full journal. Keith Loring, MD, is an emergency physician at St. Mary’s and CPMC Davies hospitals, an SFMS board member, and an active member of the San Francisco Emergency Physicians Association. Steve Heilig is with the SFMS and is a former Robert Wood Johnson drug policy fellow. Comments are closed.
