Two years ago a few of my ED colleagues and I tried to tackle the treatment of ED chronic pain patients at both a departmental and institutional level. We have a somewhat unique set-up in that we are an enormous academic center with a large outpatient clinic system in a region with few competing hospitals. As many of our patients already have primary care doctors within our system, we felt this was an issue that could and should be addressed interdisciplinarily. We developed a task force which included several key players from our department, the outpatient clinics, social services and the chief of medicine. Although we all agreed this was an issue that adversely affected both departments, the group was shelved when it became quickly apparent that neither department was ready to commit the resources, time and effort it would take to make such a plan medically, ethically and legally sound. We did learn a great deal from this process, however, and would advise others to consider the following when developing their own plan.
1) Define your goals. What do you hope to accomplish? The development of a more unified approach to chronic pain management, a legal habitual file, ED pain contracts, outpatient referrals to pain clinic or rehab, or the identification of peddlers?
2) Start in your backyard. The management of chronic pain in the ED is a contentious and visceral topic. Your group and its respective Dr. Sugar Daddys and Dr. Sugar Pills will need to sit down and agree upon some general principles that you hope your “guideline” will accomplish. The following should be considered.
-Will patients or complaints (toothache/low back pain) be targeted?
-If you plan to track patients how will this occur?
-Who decides? (Hint: physician group consensus, not an irritated triage nurse.)
-How will they be identified in future visits?
-Who will have access to the information?
Are you going to develop prescribing guidelines?
-Type of medicine- NSAID, opioid, long acting opioid, muscle relaxants, benzodiazepines
-Number prescribed- and will this be modified depending on frequency of visits per month?
-Capsule versus pill- some feel capsules have less street value
Is there a threshold when an additional intervention should be considered?
-When should PCP be notified?
-When should social services be involved?
3) Get your risk managers involved early. Although nothing in EMTALA states that ED patients have the right to an opioid script, the Board of Medicine has disciplined doctors for the undertreatment of pain. It is important to get your legal department involved so your policy complies with current institutional guidelines and state law. If done hastily, you could be setting your group up for a law suit based on a claim of failure to treat, discrimination or abandonment.
4) Use information technology (I.T.) With more departments using electronic records it is much easier to track prior visits and prescribing habits. Some states now have data banks which can be assessed to determine if the patient is receiving multiple scripts from multiple providers (such as the Kasper program in Kansas.) I.T. can also help you set up habitual files or access pain contracts in confidential, limited access files complying with legal standards.
5) Use support services. Are there legitimate barriers which are preventing the patient from receiving appropriate outpatient services? Social workers and case managers may be extremely helpful in this regard. As chronic pain and depression often go hand in hand, you might also consider setting the patient up with a mental health provider.
6) Reach beyond the ED. If the patient does not have a primary care doctor, is there a clinic they should be referred to? Ideally, this clinic would be one which your ED has already worked with to set up the following:
-A non-punitive comprehensive chronic pain management treatment plan that includes suggestions for the ED management of breakthrough pain
-I.T. involvement so that the clinic can follow frequency of ED visits and medications prescribed and the ED can follow compliance of outpatient follow up
7) The final straw. For those patients who are non-compliant with outpatient follow up and who are seen for multiple visits requesting an opioid script, it is possible to work with your legal department to send them a letter (with a copy placed in a confidential portion of their medical record/habitual file). This letter should state what treatment plan they should anticipate receiving during their next ED visit. If the patient returns for a non-acute pain issue the letter can be handed to him and the treatment plan enacted. These letters must be very carefully crafted. If the language suggests that the patient should not or may not return to the ED, it may be interpreted as an EMTALA violation.
Standardizing your department’s approach to chronic pain patients is a worthy goal. It may reduce abuse and dependence, provide necessary resources for patients who need them, divert patients to more appropriate settings, improve physician patient relationships and help with staff morale. There are no quick fixes, however, and these plans take long-term commitment and resources by all involved parties. Timing is important too. In the past two years at my own institution we have greatly enhanced our system wide electronic medical record. As this allows a much easier way to track our patients, there is renewed interest in addressing this problem. At the end of the day it is important to remember that whether we do or do not prescribe a specific medication during a specific visit, all of our patients deserve to be treated in a professional and respectful manner.