Chronic Pain Management in the Emergency Department: Challenges and Opportunities

1. Chronic Pain Management in the Emergency Department: Challenges and Opportunities Dawn Prall, MD, FACEP Richard Nelson, MD, FACEP Panel Members April 5, 2011

2. Panel Members Michael Bourn, DO Chris Erickson, MSW, LSW Lisa Fallara, MSW, LISW-S, ACM Erika Kube, MD, RDMS Maury Witkoff, DO, FACOEP, FACEP

3. Objectives Following this presentation, participants will be able to: • Discuss several challenges of chronic pain management in the emergency department setting • Understand the function of the emergency department in the continuum of care for patients with high risk disease • Learn about the importance of care provider communication for ongoing management of this high risk population • Develop a plan for improving ED care of patients with chronic pain

4. Basic tenant Health care providers who are practicing good medicine and keeping appropriate medical records have nothing to fear.

5. Definitions • Acute Pain: “Acute pain follows injury to the body and generally disappears when the bodily injury heals.” • (American Pain Society, “ Pediatric Chronic Pain,” ttp://www.ampainsoc.org/advocacy/pediatric.htm ) • Acute pain is often a SYMPTOM, not a disease state. (see definition of chronic pain) • Chronic Pain: “…chronic pain serves no such physiologic role [compared to acute pain] and is itself not a symptom, but a disease state. It is usually defined as pain which lasts beyond the ordinary duration of time that an insult or injury to the body needs to heal. This is commonly thought of as four to six weeks, although others have chosen 3 months….The difference is semantic…” • (UptoDate, “Definition and Pathogensis of Chronic Pain,” http://www.uptodate.com/contents/definition-and-pathogenesis-of-chronic-pain )

6. Definitions • 2 types of chronic pain • Cancer-related pain • Non-cancer pain

7. Pain Grid Courtesy of Craig Pratt, MD (with some changes)

8. The goal of pain management is not necessarily pain relief – it is improving a patient’s quality of life.

9. Definitions • Dependence: “…means that a person needs a drug to function normally. Abruptly stopping the drug leads to withdrawal symptoms.” • (medline plus, “Drug Dependence”, http://www.nlm.nih.gov/medlineplus/ency/article/001522.htm ) • Addiction: “Drug addiction is the compulsive use of a substance, despite its negative or dangerous effects.” • (medline plus, “Drug Dependence”, http://www.nlm.nih.gov/medlineplus/ency/article/001522.htm ) • Pseudoaddiction: “…defined as behaviors that appear to indicate addiction but actually reflect undertreated pain.” • (medscape, http://www.medscape.com/viewarticle/519760_2 )

10. Definitions • Drug Diversion: “Diversion is the unlawful channeling of regulated pharmaceuticals from medical sources to the illicit market place. Diversion can occur along all points in the drug delivery process including: • Manufacturing site • Wholesale distributor • Physician/prescriber • Retail pharmacy • Hospitals • Patient” • (“The Burden of Poisoning in Ohio, 1999-2008.” Violence and Injury Prevention Program, Bureau of Health Promotion and Risk Reduction, Office of Healthy Ohio, Ohio Department of Health, section 4, pg. 82.)

11. Why do we need to know the difference? • Addiction • Pseudoaddiction • Dependence • Diversion Because it drastically alters our understanding of the patient’s problem and can change the course of treatment

12. Definitions • Doctor Shopping: ““Doctor shopping is a form of diversion conducted by patients. Doctor shopping typically involves a patient going to a few different doctors complaining of a range of symptoms in order to obtain multiple prescriptions. Previous studies have defined doctor shopping as obtaining prescriptions for medications from at least five or more different physicians within one year.” • (“The Burden of Poisoning in Ohio, 1999-2008.” Violence and Injury Prevention Program, Bureau of Health Promotion and Risk Reduction, Office of Healthy Ohio, Ohio Department of Health, section 4, pg. 82.)

14. Suggestion Avoid using the term “drug seeking” • Negative connotation • Used liberally, often inappropriately • Technically can apply to addicted/dependent vs simply dependent individuals; for simplicity sake, the difference is in the behavior

15. Chronic benign pain • Disease process, not a symptom • Distinctly different than cancer and acute pain • Sickle cell and some other diseases fall in grey areas because of risk of serious complications of the disease itself • Chronic benign pain has many causes with less certain cure or treatments

16. Ohio State Medical Board 4731-21-02 Utilizing prescription drugs for the treatment of intractable pain

17. Ohio State Medical Board 4731-21-02 Utilizing prescription drugs for the treatment of intractable pain “When utilizing any prescription for the treatment of intractable pain…a practitioner shall …” • Perform a complete H&P that includes pain history, substance abuse history, etc. • Document how pain on the patient’s physical and psychological functions; • Document previous diagnostic studies and therapies • Must justify why prescription pain medication should be used • Must document consent to treatment after being informed of the benefits and risks of receiving prescription drug therapy on a protracted basis • Monitor effect of treatment through follow up • Assess for addiction and consult addiction specialists if indicated How often do emergency care providers actually do all of this? NEVER!

18. Utopia • Patients who trust that the health care system will work with them to manage their disease fully • Good incentives for care providers in caring for and monitoring those with chronic pain • Plenty of resources and time to manage individuals with chronic pain, as well as those who have mental illness and addiction • Law enforcement, mental health and addiction services work well together and with the rest of the healthcare system to provide care for patients

19. Reality • Overwhelmed healthcare system that reimburses less for preventative health than interventions, including poorly funded mental health and addiction services • Lack of oversight or care coordinators for patients who need it • Readily available controlled substances on the street or in the medicine cabinet with a willing population who self-medicate • Overwhelmed legal and mental health system • Lack of addiction services • Pts think controlled substance medications are safe because they come from a doctor …even if they personally do not get them from their doctor

20. What reasons do emergency physicians give to justify writing prescriptions? • The Joint Commission (TJC) • EMTALA • Press-Ganey (ie patient satisfaction) • Limitations of OARRS system • Others?

21. The Joint Commission • Emphasizes pain control and monitoring • Pendulum swung all the way, and is now just starting to swing back

22. EMTALA

23. EMTALA • Emergency Medicine Treatment and Active Labor Act: 1986 • Three components: • screening examination • stabilizing treatment • appropriate transfer Hospitals with specialized capabilities are obligated to accept transfers

24. EMTALA Covers: Insured Uninsured Medicare Medicaid Prisoners Foreigners Undocumented aliens Children Space aliens Etc.

25. Definition of emergency medical condition ..a medical condition of sufficient severity (including severe pain, alcohol or drug intoxication and psychiatric manifestations) that the absence of immediate attention could expect to result in: (a) placing the patient’s health in serious jeopardy; (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part

26. ….And how does one determine if an emergency medical condition or active labor exists??????????????

27. Medical screening examination ..the hospital must provide for an appropriate medical screening examination within the capability of the hospital’s emergency department to determine whether or not an emergency medical condition exists

28. Triage evaluation is NOTconsidered a medical screening examination under EMTALA

29. What constitutes a “medical screening examination”?

30. And what happens if the medical screening examination determines that an emergency medical condition exists?????????????

31. Necessary stabilizing treatment ..if a patient presents with an emergency medical condition the hospital must stabilize the medical condition within the available staff and facilities including on-call physicians, or provide for an “appropriate transfer”

32. And what happens if the medical screening examination shows that an emergency medical condition does NOT exist, or if there was an emergency medical condition, but it was stabilized ?????????????

33. EMTALA no longer applies

34. Patient Satisfaction Scores • Physician salary, bonus, and employment may be linked to scores • Group contract with hospital may be linked to patient satisfaction scores • Press-Ganey surveys patients directly on pain control

35. Almost no data on effects of restrictive narcotic use policies and patient satisfaction scores • There are data to link adequate pain control to patient satisfaction scores • Data show that good communications skills are linked to high patient satisfaction scores • Perception that patients who are truly drug seeking are unlikely to respond to patient satisfaction surveys

36. OARRS (Ohio Automated Rx Reporting System) • Established by State Board of Pharmacy in 2006 • Reports scheduled prescriptions filled at pharmacies in Ohio, usually within 10 days

37. Advantages of OARRS • Reasonably up to date • Available 24/7 • Early data suggest OARRS checks may affect physician prescribing behaviors • Baehren et al: management changed in 41% of cases; 61% resulted in fewer or no opiods prescribed; 39% resulted in more opiods prescribed than previously planned

38. Challenges with OARRS • Lengthy registration period • Time consuming (up to 3.5 minutes per report) and must be done by physician or designee • Reports often delayed • No consensus on what constitutes a “positive” OARRS check (eg multiple providers, multiple pharmacies, many prescriptions, etc) • Opiods sold or dispensed directly at physician’s office are not reported • VA prescriptions also not reported to OARRS • No access to out of state prescriptions • OARRS reports are difficult to interpret • Downtime (system backups)

39. About OARRS • Accessible currently by • Physicians • Licensed professionals • Pharmacists • Some law enforcement officials • Legislation expected to pass in the next few weeks allowing supervised access of non-licensed physicians (MAs, office managers, etc)

40. Mandatory OARRS checks?? • Do you need to do a check on a patient with an obvious source of pain? • Two physicians may interpret the same report differently • Delays in patient care • What do you do with the information?

41. Where does the emergency department fit in the management of chronic benign pain?

42. Where does the emergency department fit in? • Chronic pain is often not life threatening but can mask more serious disease • Evaluation for life and limb threatening illness or injury is appropriate • Once evaluation is complete, if pain is determined to truly be chronic benign pain, where do we go from here?

43. Where does the ED fit in managing patients with chronic non-cancer pain? • Coordination of care with the patient’s primary pain management doctor is CRUCIAL • Otherwise, the patient gets care independently from multiple providers and is at risk for self medication and adverse events of care • ED should help reinforce guidelines set forth by the patient’s primary pain management physician

44. Where does the ED fit in managing patients with chronic non-cancer pain? • Occassionally, ED care is appropriate for flares of chronic pain but should be rare – remember EMTALA • Care plan should be developed with primary pain management physician PRIOR to flares of pain • Social work and case management often helpful

45. This is why phone call to the patient’s primary pain management doctor are important • Set limits for expected behavior prior to the interaction via department policy • Setting time limits can be helpful and APPROPRIATE– i.e., only calling the pt’s primary care physician during normal business hours – not evening or weekends • Reinforces the need for patients to be proactive about their care

46. Otherwise, patient guidance and education are appropriate, with recommendations for non-controlled substance management • Mental Health resources (including counseling) • Non-controlled substance medications • Warm/cool compresses • Chiropractor • Acupuncture • Massage • Addiction resources if applicable • etc

47. Where does law enforcement fit in? DEA – target regional and national issues Local law enforcement – target individuals ~ Often have a hotline or non-emergency number anyone can call

48. QUESTION: what is the best way to care for patients with chronic pain in the ED? a) Give the patient whatever they want and send them on their way. Let’s face it, the ED is busy and we need to open up the bed. b) Give the patient a prescription for Percocet, give them their discharge papers and tell them not to come back. c) Educate patients about chronic pain as a chronic disease, talk with them about the risks of controlled substance medications, offer alternative, non-controlled substance therapies, offer hope for a good quality of life. Educate them about the importance of long-term outpatient follow up by 1 primary care physician, use of 1 pharmacy and 1 hospital system/ED to manage their disease(s).

49. What is the risk of current practice? • Missed illness or disease • It is easy to miss potentially bad disease in this challenging population • Repeated visits that reinforce unhealthy behavior • Prescribers contributing to rising death rates and addiction • No continuity of care • Increasing ED volumes for disease processes not well managed in the emergency department

50. Some statistics Many thanks to Christy Beeghly at the Ohio Department of Health for most of this data