Background

1. Utilization of the Emergency Department by Chronic Pain Patients to Obtain Pain Medications:A Study of Barriers to Treatment, Abusive Behaviors and Psychological Factors • Scott M. Fishman, MDChief: Div. of Pain MedicineDept. of Anesthesia & Pain MedicineUC Davis Medical CenterProfessor of AnesthesiologyUniv. of California, DavisSchool of Medicine

2. Background • Mayday Foundation RFP • ED paper • Literature review • Chronic pain evaluation • LBP • Headaches • Sickle Cell • Ureterolithiasis Wilsey, Fishman, Rose, Papazian, Pain management in the ED. Am J Emerg Med 2004; 22: 51-7

3. Barriers to Treatment • Quantitative data • Questionnaires • Patients • Physicians • Nursing staff • Qualitative analysis • Interviews • On perceived barriers to care in the ED from the perspective of physicians

4. Utilization of the Emergency Department by Chronic Pain Patients to Obtain Pain Medications: A Study of Barriers to Treatment, Abusive Behaviors and Psychological Factors Scott Fishman, MD, Barth Wilsey, MD, Ingela Symreng, PhD, Dan Mungas, PhD, Christine Ogden, BS

5. Overview • Study Structure • Method of Recruitment • Selected Population ~ Patient Demographics ~ Provider Demographics • Status of Recruited Patients • Successful and Failed Recruitment Techniques

6. Study StructureVisit 1 • Subject recruited while they are in the ED to be treated for chronic pain, duration  6 months • Fill out as many questionnaires as possible • Demographics, CAGE and Compton/Jameson Questionnaires • I-S.O.A.P., C.M.S.D., P.B.Q., PDQ-4+, C.S.Q., C.P.S.S., S.E.F., S.E.O.S., STAI, and BDI-II • Subject given contact information • Advised of a F/U appointment with the psychologist • Scheduled within 14 days after the ED visit

7. Study Structure Visit 2 • Subject contacted within one week of ED Visit to schedule a F/U visit with psychologist • If all questionnaires are not complete • Opportunity at time of F/U visit to complete all questionnaires • The patient will meet with the psychologist for the S.C.I.D. • After meeting with the psychologist, the patient is informed about payment for participation • Completed Subject • A set of complete questionnaires, BDI-II, and S.C.I.D. evaluation

8. Method of Recruitment – Academic Offices • Ability to view the ED “Whiteboard” via remote computer in our Academic Offices enables remote screening • Research Assistants can utilize computers to look for patients who complain of the following generalized symptoms: ~ Chronic or Mild Stable Pain ~ Chronic Back Pain ~ Headache ~ Earache ~ Rx Refill Request ~ Diffuse Body Pain ~ Vague Abdominal Pain • Students travel to the ED to recruit these identified subjects

9. Method of Recruitment – ED • Students within the ED have significant access • Electronic “Whiteboard”, patient charts, and physical “Whiteboard” • Patients recruited using the inclusion/exclusion criteria designated by the protocol • Students approach patients within different Areas, including the waiting room, where they will proceed through the following steps: • Brief introduction to the study • Informed Consent • Administration of Study Questionnaires • Collection of all study materials before student and/or patient departs from the ED

10. Continued Contact Post ED Visit A Research Assistant will contact subject via telephone within 1 week of the initial ED visit At this time, the subject is scheduled to complete Visit 2 within 14 days of the initial ED visit The subject is contacted by telephone up to three times before the patient will be discontinued due to lack of compliance

11. Inclusion Criteria Male/Female  18 yrs of age Patient is being seen at the University of California Davis ED for Schedule II medications Patient has had pain for 6 months or longer prior to enrollment for which schedule II medications are already being prescribed Patient presents to the ED with a complaint of vague head, abdomen, or back pain of nonacute onset, diffuse body paint, etc Patient is able to read, understand, and voluntarily sign the approved informed consent form prior to the performance of any study specific procedures Exclusion Criteria Patient arrived by ambulance Patient has an emergency medical condition Patient states that they are not comfortable reading and comprehending English Patient is unwilling or unable to comply with the study visit schedule Subject Selection

12. Patient Demographics: Gender n =77

13. Patient Demographics: Duration of Chronic Pain n = 76

14. Patient Demographics: Ethnicity n = 83

15. Patient Demographics: Annual Income n = 70

16. Patient Demographics: Education n = 73

17. Patient Demographics: Employment n = 73

18. Currently Employed : Line of Work ~Building Maintenance ~ Scrub Technician ~ Construction ~ Testing Technician ~ Stock Worker ~ Telemarketer ~ Editor ~ Housekeeper ~ Receptionist ~ Physical Therapist ~ Luggage Handler ~ Drug and Alcohol Counselor ~ Customer Service Clerk ~ Environmental Manager ~ Wildland Firefighter ~ Mental Health Worker ~ Writer ~ Cable ~ Truck Driver ~ Musician Currently Unemployed: Longest Employment ~Fence Builder ~ Cable ~ Presser/Dry Cleaner ~ Dock worker ~ Retail Management ~ Contractor ~ Engineering Technician ~ Housekeeping ~ Insurance ~ Janitor ~ Figure Skater ~ Painter ~ Analytical Chemistry ~ Roofing ~ Asst. Supervisor for Distrib. ~ Lumberjack ~ Homemaker ~ Homemaker ~ Nursery Employee ~ Truck Driver ~ Underground Construction ~ Cashier ~ Limousine Company ~ Army ~ Restaurant Work ~ Cook ~ Bakery Machine Operator ~ Healthcare Research ~ Fast Food Customer Service ~ Cabinet Worker ~ Warehouse Worker ~ Plumbing/Electrical ~ Operating Engineer Miner ~ Computer Programmer ~ Office Furniture Installer ~ Mechanic ~ Mental Health Case Mgr. ~ Welder/Fabricator ~ Accounting ~ In House Security ~ Sales Types of Employment

19. Provider Demographics

20. Provider Demographics: Different Providers n = 56

21. Provider Demographics: Gender n = 53

22. Provider Demographics: Ethnicity n = 48

23. Status of Study Subjects Completers vs. Non-Completers

24. Completers vs. Non-Completers n = 90

25. Non-Completers: • Patients have or have not completed some portion of the questionnaires. They have NOT completed the S.C.I.D. • Total: 51/90 = 56% ------------------------------------------------------------------ - No Information Collected : 2 * Dem = Demographics -CAGEOnly : 1 **C\J = Compton\Jameson -Dem*,CAGE: 13 - Dem,CAGE,C\J**: 11 -Dem,CAGE,C\J, I-S.O.A.P. : 2 -Dem,CAGE, C\J, I-S.O.A.P.,CMSD : 1 -Dem, CAGE, C\J, I-S.O.A.P.,CMSD, PBQ, STAI : 1 -Dem, CAGE,C\J, I-S.O.A.P.,CMSD, PBQ, PDQ-4+:1 -Dem, CAGE, C\J, I-S.O.A.P.,CMSD, PBQ, PDQ-4+,BDI-II: 2 -Dem, CAGE,C\J,I-S.O.A.P.,CMSD, PBQ, PDQ-4+,CSQ: 1 -Dem,CAGE, C\J,I-S.O.A.P.,CMSD, PBQ, PDQ-4+,CSQ, CPSS, SEF, SEOS: 1 - Dem, CAGE, C\J, I-S.O.A.P.,CMSD, PBQ, PDQ-4+,CSQ, CPSS, SEF, SEOS, STAI: 8 - Dem, CAGE, C\J, I-S.O.A.P.,CMSD, PBQ, PDQ-4+,CSQ, CPSS, SEF, SEOS, STAI, BDI-II: 7

26. Completers: Patients have completed all necessary questionnaires AND the S.C.I.D. Total: 39/90 = 43% ---------------------------------------------------------------------------------------- Dem,CAGE, C\J,I-S.O.A.P., CMSD, PBQ, PDQ-4+,CSQ, CPSS, SEF, SEOS, STAI, BDI-II, S.C.I.D. : 39

27. Summary of Recruitment Successful Strategies and Barriers

28. Useful Recruitment Strategies ~Presence of recruiter in the ED between the hours of 11am-8pm M-F (five day coverage to maximize patient recruitment) ~ Patient completion of BDI-II along with as many questionnaires as possible within the ED Barriers to Recruitment ~2nd Visit does not receive as much of a response from patients ~ 2nd visit can only be completed on Fridays ~ Excluding patients who arrive by ambulance: Some chronic pain patients, utilize the ambulance to “get a ride” to the ED. ~ 14 day interval between visits is too small Recruitment

29. Quantitative Study of Barriers • Questionnaire for Patients & Providers • Same questions • Framed differently

30. Patient I do not have adequate time to assess and treat ED patients complaining of chronic pain Provider Doctors and nurses avoid spending enough time to talk about your chronic pain Lack of Time

31. Strong agreement 5 Moderate agreement 4 ] Some agreement 3 ] ] Some disagreement 2 Moderate disagreement 1 Strongly disagreement 0 nurse patient physician Dunnett t-test post-hoc ns patient vs physician .113 sig patient vs nurse .003 n=37n=54n=19 lack oftime

32. Provider The treatment of chronic pain in the ED takes a back seat to treatment of more pressing issues like trauma or myocardial infarctions Patient Doctors and nurses have more pressing issues than chronic pain (like seeing injured people or those with heart attacks) Prioritization

33. 5 ] ] 4 ] 3 2 1 0 nurse patient physician Strongagreement Moderate agreement Some agreement Some disagreement Moderate disagreement Strongly disagreement Dunnett t-test post-hoc ns patient vs physician .184 ns patient vs nurse .075 n=37 n=54 n=19 more pressing issues

34. Provider Chronic pain has little chance of improving Patient Chronic pain has little chance of improving Fatalism

35. Strong agreement 5 Moderate agreement 4 ] Some agreement 3 Some disagreement 2 ] ] Moderate disagreement 1 Strongly disagreement 0 patient physician nurse n=37 n=54 n=19 Dunnett t-test post-hoc sig patient vs physician .001 sig patient vs nurse <.001 Little Chance of Improving

36. Provider I do not believe the validity of a pain complaint in the absence of physical findings or a lack of objective findings on imaging studies, EMG, etc Patient When the doctor cannot find something wrong on exam or by an X-ray, they tend not to believe you could be in pain Belief in Pathology

37. Strong agreement 5 Moderate agreement 4 ] Some agreement 3 Some disagreement 2 Moderate disagreement ] 1 ] Strongly disagreement 0 patient physician nurse n=37 n=54 n=19 Dunnett t-test post-hoc sig patient vs physician .001 sig patient vs nurse <.001 Belief in Pathology

38. Provider I believe that chronic pain patients who come to the ED are addicted to their pain medications Patient I think that I am addicted to pain medications Fear of Addiction

39. Strong agreement 5 Moderate agreement 4 Some agreement 3 ] Some disagreement 2 ] Moderate disagreement 1 ] Strongly disagreement 0 patient physician nurse n=37 n=54 n=19 Dunnett t-test post-hoc sig patient vs physician .003 sig patient vs nurse .001 Fear of Addiction

40. Provider I avoid administering opioids because patients will develop physical dependence and go through withdrawal when they abruptly halt the intake of the medicine Patient I avoid taking pain medications because taking them will lead to withdrawal symptoms if I have to stop them Fear of Dependence

41. Strong agreement 5 Moderate agreement 4 3 Some agreement 2 Some disagreement ] Moderate disagreement 1 ] ] Strongly disagreement 0 patient physician nurse n=37 n=54 n=19 Dunnett t-test post-hoc sig patient vs physician .018 sig patient vs nurse <.001 Fear of Dependence

42. Provider I find myself labeling chronic pain patients as “bad patients” or “drug seekers” Patient I believe that telling doctors and nurses about my pain leads them to consider me to be a “bad patient” or a “drug seeker” “Bad” Patient

43. Strong agreement 5 Moderate agreement 4 Some agreement 3 ] Some disagreement 2 ] ] Moderate disagreement 1 Strongly disagreement 0 patient physician nurse n=37 n=54 n=19 Dunnett t-test post-hoc ns patient vs physician .108 ns patient vs nurse .313 “Drug Seeker”

44. Qualitative Research Through Interviews • Access using conversations and consultations with ED physicians • Taped and transcribed interviews • Anonymity and confidentiality maintained

45. Qualitative Research • Questions • Most problematic chronic pain patient • Limitations on care • Potential sources of improvement

46. Qualitative Research • Responses • “ED not designed to see these patients” • “Appropriate referrals to pain specialists difficult” • Advised patients “find a primary care doctor” • Provide short acting opioids • 20-30 pills of vicodin, codeine, or oxycodone

47. Estimated Numbers (in Millions) of Lifetime Nonmedical Use of Selected Pain Relievers among Persons Aged 12 or Older: 2002 http://oas.samhsa.gov/2k4/pain/pain.htm

48. Abusive Behaviors

49. Estimated Numbers (in Millions) of Persons Aged 12 or Older with Past Year Illicit Drug Dependence or Abuse, by Drug: 2002 http://oas.samhsa.gov/2k4/pain/pain.htm\

50. Prescription Drug Abuse in ED • Modeling using multiple regression • Dependent variable • Screener and Opioid Assessment for Patients in Pain (SOAPP) • Independent variable • Spielberger State-Trait Anxiety Inventory (STAI) • Beck Depression Inventory (BDI-II) • Chronic Pain Self-Efficacy Scale (CPSS) • Coping Strategies Questionnaire (CSQ)