Pain and the Emergency Department

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What have you learned about the management of pain in the ED, and what pain patients might be at higher risk for poor care? 

How are patients with chronic pain disorders treated in the Emergency Department?

Read through the first roundtable of a two part series with 4 experts in the field of pain treatment. Part one deals with experts discussing some of their thoughts on the quality of care pain patients recieve in the Emergency Department.

Knox Todd, MD:

Knox Todd, MD, is the Director of the Pain and Emergency Medicine Institute, Department of Emergency Medicine, Beth Israel Medical Center, Albert Einstein College of Medicine, New York, NY, and the author of many publications on pain management.

Many research studies document problems with pain management in Emergency Departments. This problem, termed “oligoanalgesia,” is the common under-utilization of analgesics. There are multiple reasons for this problem. In spite of the frequency of the complaint of pain, Emergency Department personnel still need a lot of education to improve their understanding and treatment of both acute and chronic pain. The numbers of patients seeking help are large. Approximately 70% of patients going to the ED have pain, and as many as 40% of these have an underlying chronic pain condition. Of this group, half of this number may be having an exacerbation of their chronic pain. Teaching Emergency Department personnel about pain is a large part of my daily work.

Unfortunately, Emergency Departments are increasingly stressed by their growing numbers of patients. It is important to understand that the Emergency Department is not the ideal place to manage many chronic medical conditions, due to the time and resource limitations and the need to prioritize care. Unfortunately, some patients with chronic pain may not have a competent health care provider who is willing to manage their pain, and these patients will keep turning to the ED, where the complex assessments and planning that patients deserve may not be possible.

Physicians in the Emergency Department want to provide the best care for the patient without causing harm. ED personnel are also very conscious of the problem of substance misuse and the first question that will come to mind for many physicians is whether the patient is displaying inappropriate drug seeking behaviors. When I meet with these physicians I ask them how well they believe they are able to diagnose addictive behavior, and if they know how to distinguish between addiction, tolerance, pseudo-addiction, (behaviors that may develop in response to the under-treatment of pain) and criminal intent. They often respond that they don’t have sufficient training in making these judgments.

In addition to not having a primary care provider, there are many other reasons that patients may seek care in an ED, and some of these may be problematic. There are patients who are in a conflict with their primary care physician with regard to the need for opioids, or those who have personality disorders or psychiatric diagnoses that result in poor continuity of care, and, although uncommon, those who have a criminal intent and seek to receive and sell drugs. These are all things a physician in the ED considers in making opioid prescribing decisions. In reality, physicians in the ED rarely prescribe more than a small amount of opioids at any one time, and the likelihood of societal harm from inappropriate prescribing is small.

In terms of health care disparities, our research has shown that both the very young and the very old patients are at a higher risk of experiencing less analgesia in an Emergency Department, as well as patients who are not white. Patients who are known substance abusers are at a very high risk of having their pain under-treated. Unfortunately, so are chronic pain patients. We recently partnered with the American Chronic Pain Association to conduct an Internet survey and found that 47% of the 258 patients surveyed defined their visit to the Emergency Department as “poor”, “terrible”, or “the worst experience of my life.”

What have you learned about the management of pain in the ED, and what pain patients might be at higher risk for poor care? 

How are patients with chronic pain disorders treated in the Emergency Department?

Read through the first roundtable of a two part series with 4 experts in the field of pain treatment. Part one deals with experts discussing some of their thoughts on the quality of care pain patients recieve in the Emergency Department.

Jim Broatch, MSW:

Jim Broatch, MSW, is the Executive Director of the Reflex Sympathetic Dystrophy Association in Milford, CT (www.rsds.org) 

Usually I hear about RSD patients and their experiences in the Emergency Department from their anecdotal reports when they contact us. I hear a lot of “horror stories”. The common elements are that patients wait a long time to be seen, then are given a “dressing down” for having come to the ED, and are “sent packing” without treatment. Together with Johns Hopkins University we posted a questionnaire on our website about patient experiences in the Emergency Department. There were 1,362 responses to the questionnaire and 44% reported a negative experience.

With our patients we have the situation of a disease that is a rare syndrome which most physicians still have still not heard about or understand. Our organization was founded in 1984 by the mothers of two children who had developed RSD as a result of childhood injuries. A major goal of our organization is to develop better awareness of the problem of RSD. Not long ago one of our patients traveled to a large hospital to be seen by a specialist in RSD. While an inpatient there he felt “manhandled” by the medical team. Upon his return he asked our scientific advisory committee to develop a fact sheet about reflex sympathetic dystrophy that could be given to hospital personnel when a patient with RSD is admitted to the hospital. We are now thinking of developing a similar document for use in Emergency Departments.

The document we developed is titled “Hospital Protocol RSD/CRPS Patient: Handle With Care!” The first paragraph reads “Reflex Sympathetic Dystrophy (RSD) also known as Complex Regional Pain Syndrome (CRPS) is a chronic condition characterized by severe burning pain, pathological changes in bone and skin, excessive sweating, tissue swelling and extreme sensitivity to touch. People afflicted with RSD/CRPS are extraordinarily sensitive to certain stimuli, such as touch, movement, and injections.” The document goes on to list over two dozen specific suggestions for a care plan in areas including: setting up the patient room; performing medical procedures; taking blood pressure and pulse rate; transporting; feeding; and identifying RSD patients.

What have you learned about the management of pain in the ED, and what pain patients might be at higher risk for poor care? 

How are patients with chronic pain disorders treated in the Emergency Department?

 

Rochelle Odell:

Rochelle Odell is a former health care provider (EMT and ICU Nurse Technician) now disabled with CRPS and chronic pain. She is the founder of the organization “CRPS/RSD Education in Emergency Departments (CEED)”. She initially contacted PainEDU in June, 2006 about her experiences with emergency department care and her story led us to develop this series of interviews. If you are interested in contacting her, please write to her at ofrdrsq@aol.com

I developed CRPS which is now in Stage III. I am on many medications and I am under the care of a pain specialist. When needed, my primary care provider and the HMO which provides my health insurance coverage, direct me to their contracted hospital (not where my pain specialist is) for emergency department care. It is like pulling teeth to get me to go to the ED when I have a major pain flare up as I would generally describe my care there as substandard. Emergency Department physicians do not seem to understand the concept of breakthrough pain. Like many patients with CRPS, the fact that I am on high doses of oral pain medications (opiates) makes the ED physician nervous. I can’t count the number of times I have been told by an ED nurse that the doctor doesn’t want to give you any IV or IM pain medicines because “it puts him out of his comfort zone.”

In my experience doctors in emergency departments know little if anything about CRPS, and may run needless tests, some of which can be painful. In my experience, the doctors don’t check the little book they all carry that tells them how to convert a patient’s oral dose to an IV dose. Unfortunately, it is a rare ED physician who will call the patient’s Primary Care doctor or better yet, the Pain Management physician, to find out the best way to care for us. I have developed a questionnaire to gather the experiences of CRPS patients, and I have collected some real “horror stories”. I hope to get the CRPS/RSD Education in Emergency Departments (CEED) organization off the ground. I chose this acronym because I want it to represent this idea: “planting the “CEED” of knowledge in all Emergency Departments about the never ending burn pain of CRPS/RSD.”

I was an ICU nurse technician. I believe the groups of people who receive the poorest care are single women and minorities. I say this from all of the ED horror stories I received, as well as from my own experiences. If we are not given adequate pain medications, and ask for more, it takes the RN forever to get another injection. Then the doctor starts to raise his eyebrows and I know he is thinking I am a drug seeker, when I am suffering from an intractable pain episode.

What have you learned about the management of pain in the ED, and what pain patients might be at higher risk for poor care? 

How are patients with chronic pain disorders treated in the Emergency Department?

Read through the first roundtable of a two part series with 4 experts in the field of pain treatment. Part one deals with experts discussing some of their thoughts on the quality of care pain patients recieve in the Emergency Department.

Alan Witkower, Ed.D.:

Alan Witkower, Ed.D.,is a Psychologist and the Assistant Director, Outpatient Pain Service, Associate in Psychology, Department of Psychiatry, Massachusetts General Hospital, and Instructor in Psychology, Harvard Medical School

My knowledge of the management of pain in the Emergency Department, with the exception of what I have read on the topic, is based on the anecdotal reports from my patients. I treat many patients with intractable pain who are being managed with chronic opioid therapy. Many of these patients will require an occasional Emergency Department visit. Here is an example of a not-uncommon situation.

A patient, who happens to be a minister, has chronic back pain managed with opioid pain medications, and told this story. He had a back spasm on a weekend, likely related to the fact that he recently did a lot of airline travel. He is prone to spasms and his primary care doctor was not available, so his understanding of what to do was to go to his local emergency department. He had a long wait and then spoke with a triage nurse. Initially he thought she was sympathetic, but later he felt she believed his complaint was trivial. When he met with the physician he was asked why his problem couldn’t wait until Monday. The patient explained he was worried that something more seriously wrong was causing the increased pain. He told the physician what medication he had been taking and described what he had tried to do to mitigate the pain. He said his pain was 9/10 instead of his usual 6/10. Unfortunately, (although I counsel patients to always do this) he had not brought any documentation with him. The patient reports that he was given a “cursory” examination and was told he could be given a muscle relaxant. When the patient explained that he might respond better to a temporary increase in his opioid pain medication, he was dismissed with the impression that he was viewed as a “drug-seeker”.

My experience is that the patients who have chronic headache or chronic low back pain and seek emergency care are more likely to be dismissed than patients with other chronic medical and pain disorders. My experience has taught me that weekends are the worst time for patients presenting to the ED with a pain exacerbation. I have read that there are socio-economic and racial biases, which may increase the chance of poor treatment, but in general my patients are white and middle class. While not everyone remembers to do this, I suggest that they bring their pain contract, medicine bottles, and a list of their medications and contact information for their physician, whenever they need to go to an emergency department.