EM:RAP Emergency Medicine: Reviews and Perspectives

2012  ›  January Episode

Pain Care in the ED

The cronic pain patients that continually present to your ED in search of relief..how do you approach their care? No Meds? Some Meds? Which Meds? We are here to help.

Contributors

  • Suzanne E. Johnson DO
  • Mel Herbert, MD MBBS FAAEM

Comments on Pain Care in the ED

Joshua S.

This approach makes a lot of sense and I like much of it, but how does this deal with inter-institutional crossover by patients? We have patients who travel 100 miles in all directions for pain control. Once a plan is in place at my institution, what prevents the patient from going to other hospitals in the region? Confidentiality prevents the sharing of these plans without a request and permision of the said patient.

Suzanne J., D.O.

Hi Joshua,

Thank you so much for your interest and for your question. This question has come up in several sites, and your right, requesting vicodin, will travel. Really the only way to stop this is to have a larger and larger area with similar policies (hopefully ours) in place, so that it doesn't matter where the patient goes, the answer is the same: no. The other thing to realize is that there is no perfect solution. Someone will always slip through the cracks, and I think that's OK. We stop 80-90% of the abuse, and we make the ED a much better place to work, and much safer for our patients.

Thank you again, we hope to hear from you

Dr Suzanne Johnson
Rational Pain Care.com

Alexander K., M.D.

We have a no refill on narcotics policy in out ED, howeve it is not inforced and docs always have ability to prescribes narcotic pain meds when they feel it is indicated. However, it take a lot of argument out of the discussion with the patient when you feel narcotics are not indicated/dangerous. Gives you a chance to fall back on the policy vs being a doc who does not refill my vicodin. I see drug sekers very rarely at this place. I use to work in a hospital 15 miles away and would see same people over and over again who new the drill well and would really wear you out.

gerald b.

I agree that a "policy" is a good bail out tactic. I have found that all it takes is one " candy man" in the ED, to keep the " seekers" coming. If one needs narcotics for pain, it is what it is, if not they should advised to follow up with pmd; not given " a few" to tide them over and get them out the door to avoid an arguement.

JP

The POLICY and protocol has significantly reduced our candy manning. It gives backbone to the refusal, and allows the EDMD to sidestep some of the frustration from patients if it comes from above.

Vanessa B., M.D.

We have a Consistent Care program founded by my partner, and we call it the Consistent Care Program. We and the surrounding hospitals participate. It is wonderful, and has made our ED so much more enjoyable to work as an EDMD. We now have minimal visits from chronic pain patients, because they are now part of CONSISTENT CARE.

Elicia K., MD

Who pays for this?

Jim M., DO

I like the sound of the program, but a couple of points:
1. What's the "stick" for the PCPs to participate? The majority of ones around me rely on hospitalists for their inpatients, and have the option to say no if the patient breaks the pain contract.
2. How do you get buy-in from invertebrate adminstrators that lack 2 specific bits of anatomy? Invariably these patients are somehow sent Press-Ganey surveys, with the resultant ill effect for the physician.

We have an informal policy of limiting controlled prescriptions to no more than 12 tablets and no hydromorphone. It has helped.

Maureen A., M.D.

Hi Mel Our Health care district has developed and implemented a pain strategy for our ED's recently based on Dr. Johnson's work on pain plans. It's a great tool when teaching residents as well because it provides a comprehensive approach to pain that get students to recognize it's not just about the pills we use. A key step to effective pain management in the ED is understanding the difference between acute pain and a chronic pain "flare-up" . Our use of the term acute on chronic only confuses the picture for us and the patient. Not sure how to share this with you in this format but would be happy to do if interested. The strategy also addresses addiction and diversion as part of the approach. Maureen

You must login or subscribe to comment on this segment.