When managing acute and chronic pain in the emergency department, EPs struggle to walk the line between being cold-hearted cynics and becoming sugar daddies.
Mark Plaster: Pain is one of the major reasons patients come to the ER, yet emergency physicians are notoriously unsympathetic unless it’s our pain. We seem to think that everyone is a narcotics abuser and it’s our job to make sure that they don’t get too much pain relief. Am I wrong? If I’m not, how can emergency physicians be sympathetic without being sugar daddies?
Ricardo Martinez: I think it’s a very challenging issue. There is a balance between providing relief and the risks of adverse effects from prescriptions. And we are getting pushed from both sides. On one hand we are being measured by the Joint Commission and by patient satisfaction about relief of pain. On the other side you have a lot of other pressures that create a negative stigma on docs who give too much pain med out. In general, we have to ask ourselves, “What’s our job?” Our job is to relieve the pain acutely, and secondly, continue to relieve pain after they leave the emergency department. We really need to divide this up into four categories: acute pain and chronic pain, in the ED and out of the ED. I’m concerned about acute pain. We do a very poor job because we are worried about ourselves, as opposed to being concerned about the patient. You’re not going to make somebody a drug addict in the ER. And you’re certainly not going to help them unless you take care of their acute pain. We really have to do a better job.
Greg Henry: The big pain medicine problems in the United States are not in the emergency departments. Acute pain management is not the source of addiction in this country. It may be a continuing part of it, but it’s not the cause. In my 40 years in medicine I have never created an addict in the emergency department, and I’ve never cured an addict in the emergency department by not giving them a shot of pain medicine. We believe that, “Oh my god, if you give him two more milligrams of Dilaudid he’s going to become a raving maniac glued to drugs for the rest of his life!” That’s just a bunch of crap. There is no proof of that sort of thing.
Mark Plaster: Isn’t it a legitimate fear that if you give them too much pain medication that they will return again and again and again?
Greg Henry: Yes, that’s the ‘feeding the bears’ philosophy. Don’t feed the bears because they will come back. Are there going to be those people who have worked the system? There always have been and there always will be. But I would rather treat 10 of those then deny relief to one person in real pain.
Ricardo Martinez: The bigger and more complex issue is chronic pain. The entire healthcare system doesn’t like to take care of chronic pain. Many emergency departments become the de facto place where you go when you have to get pain medication because there is a social stigma – and actually some legal concerns – associated with giving large amounts of medication as an outpatient. We find patients with chronic care who come in because they ran out of medication but they have a known disease with long term chronic pain. Quite frankly, a lot of those patients who have chronic pain come in angry and manipulative. But if you look at it, they get that way because they lost their independence and they rely on others for relief. I’m a physician and it takes me a month to get an appointment with my doctor. Good luck if you have chronic pain.
Greg Henry: I think, to a very great degree, the medical community supplies the services it wants to supply, not necessarily the services the public needs. And the truth is right now we’re in significant need of people who will manage the chronic pain patient. And these people need both medical and psychiatric experience because in all the studies, chronic pain patients (and I don’t want to get into the chicken and egg debate here) are depressed. And in medical situations, particularly with males, depression and fear are translated into anger. This is the last kind of personality a busy emergency physician wants to see. But I think in general, physicians tend to underestimate pain. You know I’m a huge fan of the 18th Century raconteur Samuel Johnson, as he said “Those who do not feel pain seldom think that it is felt.” We tend to have young healthy doctors who are not sick and are not in chronic pain.
Mark Plaster: I’m going to be the bad guy and say, Isn’t it true that prescription pain medication abuse is the number one form of substance abuse right now? And according to some, it’s actually growing? Aren’t prescriptions from the ER actually fueling this problem. Both of you are assuming that every patient has real pain.
Greg Henry: Well wait a second. You don’t know who has real pain and who doesn’t. I can’t look inside their heart. This is sort of like a line from the Green Hornet – “Who knows what evil lurks in the hearts of men? Only the Green Hornet!” Well I’m not the Green Hornet. If they’ve got pain or they say they’ve got pain, I’m willing to take that at face value. That doesn’t mean I’m willing to give them a month’s worth of narcotics. But I’m perfectly willing to agree with them that they’ve got pain. The next question is how we’re going to handle it.
Ricardo Martinez: We sometimes live in two different worlds. On the one hand we have the patient who shows up with the broken wrist but then waits 45 minutes for pain relief. But if that same patient was picked up by an ambulance, they would’ve been given Morphine en route. These EMS protocols were put in place 30 years ago. And we did that because we realized it was the right thing to do. Now what you’re talking about is all the social stigma aspects that come in extraneous to the practice of medicine. The most difficult question for the emergency physician is how much pain medicine do I give them? What we really need is some guidelines that say if someone has an acute back injury, how much pain medicine should they get, and for how long? If they have a bad fracture? If we have acute otitis, how much should they have? The answer, right now, is that nobody knows and everyone does it subjectively. And it is leading to an overreaction, where we are reluctant to give any pain medicine. Rather we tell the patient, “You need to go talk to your private physician. You need to get a doctor’s appointment.” But we also know that our ERs are full because patients can’t get to those doctors.
Greg Henry: We know everybody who comes in who has been a frequent visitor. And I have no reason to challenge their motives in the department. What I know is the pain is not being handled correctly and that they need to be referred to pain management people. Now when they refuse to go, when we’ve called up, made their appointments, this sort of thing, I still believe they probably have pain. I just don’t handle it with narcotics. There is a lot of good work on the treatment of chronic pain with everything from Ketamine to Lydocaine to lots of other methods.
Mark Plaster: We all know patients who say, “I’m allergic to Toradol. I’m allergic to ibuprofen. I’m allergic to everything but Oxycontin. And I really need my Oxycontin, are you going to write the prescription for Oxycontin?”
Ricardo Martinez: For years I practiced like everybody else. But I tell you, you get a different view when you’re the guy lying on a stretcher. About seven years ago, I was in a motor vehicle crash. We got rear ended and I ended up with tingling and burning down my arm. In short order I found myself with a neurosurgeon. I had radicular pain in C7, in fact, I lost power to my triceps in my right arm. More importantly, the pain was out of control. Yet my MRI and X-rays just showed I had small neuroforamina. I was in so much pain that I was asking the neurosurgeon to operate. I was in traction, they gave me nonsteroidals, and narcotics for pain. And quite frankly the narcotics don’t make the pain go away. They just took away that incredibly sharp edge and it made it dull. I didn’t want to get [the narcotic prescription] filled, but then I had a terrible flare-up. Well my neurosurgeon was out of town. I called a colleague of mine who does some sports medicine with me, knew my case very well, had referred me to some sports docs when we were in another city. I called him up and said, “Hey I’m out of pain medicine and I just need something for four or five days to get me over this hump.” And he said to go to the ER. This is an ER doctor. And I said, “Why is that?” He said he didn’t want to put his license on the line. I had to go to the ER, get an X-ray that showed nothing. Everyone was suspicious from the moment I walked in to talk to the triage nurse. It taught me to have compassion for those who have chronic pain and that the system doesn’t work with them.
I believe that our cynicism is widespread but what do you do when you’re concerned have an abuse problem? You can use case managers to help manage them. In truth some patients with chronic pain actually appreciate that somebody actually gives a damn and wants to set up a system for them. Some people may need to be referred for drug dependency, like you would an alcoholic and others. But you can also come up with things such as contracts; you can build relationships with private physicians. And I think one of the things that is going to help our practice immensely in the future is the growth of health information exchanges.
Greg Henry: I think the emergency docs are the least culpable in this. If you look at people who have been put on – I don’t care whether you want to talk about narcotics, benzodiazepines, etc... – we are the people who write the least amount of medication in the United States. And by the way, of the 24 board-certified specialties, the specialty that has the least impact on drugs, drug costs, that sort of thing are emergency docs – 90% of your prescriptions are for 10 days of antibiotics or seven days of pain medicine. The real problem are the people who have been put on six months worth of medicine, not seeing their doctor in between and not in a program to solve the problem. They’re just in a program to get them out of the docs office by another prescription. I think this has become universal. You shouldn’t be beating yourself up in the emergency department because you’ve given a kid with a broken arm five days of pain relief.
Ricardo Martinez: This is really an issue looking for national leadership. Emergency medicine has to realize it has the prime spot for this and many other specialties turn to the emergency department. We have to take advantage of that high ground and help solve this problem. I’m glad to see some of the specialties deciding to get into focus on it. We have to take the lead because we don’t want someone else telling us to how to practice in our unique practice environment. It’s been a missed opportunity until now.
Greg Henry: The reason that we’re a focus is because we’re open 24 hours a day, 7 days a week. If your momma don’t like you, if the police don’t want you, if your sister wants to throw you out of her house, the one place we have to see you is in the emergency department. Come on down! We will take care of you.
Greg Henry, MD
Founder/CEO of Medical Practice Risk Assessment, Inc.; past president of ACEP.
Ricardo Martinez, MD
EM educator and national healthcare consultant.