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The Journal of Emergency Medicine, Vol. 34, No. 2, pp. 125–129, 2008Copyright © 2008 Elsevier Inc.

Printed in the USA. All rights reserved0736-4679/08 $–see front matter

doi:10.1016/j.jemermed.2007.07.001

OriginalContributions

EMERGENCY MANAGEMENT OF CHRONIC PAIN AND DRUG-SEEKINGBEHAVIOR: AN ALTERNATE PERSPECTIVE

Seth C. Hawkins, MD,* Frank Smeeks, MD,* and John Hamel, MD*†

*Mountain Emergency Physicians–Blue Ridge HealthCare, Morganton, North Carolina, †Representing Blue Ridge HealthCare PainCommittee Task Force

Reprint Address: Seth C. Hawkins, MD, Mountain Emergency Physicians, Department of Emergency Medicine, Blue Ridge HealthCare,

2201 South Sterling St., Morganton, North Carolina 28655

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Abstract—Pain is one of the most prevalent conditionsreated by Emergency Physicians, although it remains con-ested how to interpret, measure, and treat this condition.n particular, there is controversy over how to identify andreat patients with chronic under-treated pain and thoseho are potentially malingering (drug-seeking). This articleiscusses currently accepted paradigms for treating poten-ially malingering patients, difficulties some communitiesay have when these paradigms are applied, and the re-

ults of implementing pain treatment guidelines that limitpioid use. Systematically limiting opioids via these guide-ines was not associated with a decrease in overall patientatisfaction, patient satisfaction with pain management,verall volume, or volume of patients with potential drug-eeking diagnoses. Emergency Physicians’ perception ofuality of care delivered, as well as job satisfaction, in-reased after implementation of the guidelines. © 2008lsevier Inc.

Keywords—pain management; pain protocols; patientatisfaction; physician satisfaction; opioids

INTRODUCTION

ain remains one of the most prevalent conditions treatedy Emergency Physicians (EPs), with some authors sug-esting that it is the most common reason to seek emer-ency care in the United States and other countries (1,2). Itsanagement is frequently addressed by specialty textbooks,

ECEIVED: 9 December 2005; FINAL SUBMISSION RECEIVED:

CCEPTED: 22 March 2007

125

ournals, lectures, and continuing education classes. Theseanagement models may be ill-suited for some environ-ents. We propose an alternate perspective.

PAIN AND CURRENT PARADIGMS OFPAIN MANAGEMENT

ain is fundamentally subjective. It does not have an ob-ective existence in our environment; instead, it exists as aeurological and emotional response to stimuli. Its presencend severity represent a composite of anatomic, chemical,nd psychosocial factors conditioned by past experiencend cultural background. Strictly speaking, the Americanain Society defines pain as an “unpleasant sensory andmotional experience associated with actual or potentialissue damage or described in terms of such damage.”

Due to its purely subjective nature and the manyactors that influence it, pain is a difficult quantity toeasure. Numerous studies have demonstrated that EPs

eem poor at accurately predicting the degree or charac-er of a patient’s pain (3–6). Many teaching programsnd textbooks have consequently adopted a paradigmhat “pain is what the patient says it is” and that allodalities should be used in the attempt to reduce the

atient’s pain. Opioids, this paradigm argues, should bethe mainstay of therapy for most of the conditions thatause moderate to severe acute pain” (1, p. 2918). With the

ebruary 2007;

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126 S. C. Hawkins et al.

ssumption that one would not utilize emergency servicesor minor pain, and research demonstrating that pain is theost common reason to seek emergency care, this para-

igm suggests that opioids should be the most commonlytilized medication in an Emergency Department (ED).

Although rare challenges can be found, for the most parthe basic philosophical underpinning of this paradigm re-ains unquestioned in Emergency Medicine literature

7,8). The remainder of this article discusses potential prob-ems with this model and outlines an alternate approach that

ay be functional for some communities.

EPIDEMIOLOGY OF DRUG ABUSE

n our non-urban community, prescription opioids areelt to be the most commonly abused opioids, comparedo more urban centers where heroin and illegal narcoticsay predominate. The prevalence of abuse of habit-

orming prescription medications and, in particular, Oxy-ontin, has received a good deal of attention in theopular press but little in Emergency Medicine literature.he safety of a given prescription drug must be consid-red in the context of the community in which it is beingsed, as well as the individual to whom it is beingrescribed. Unfortunately, opioids (which current litera-ure argues should be the “mainstay of therapy”) areontrolled substances that can be dangerous and addic-ive, and paradoxically, a frequent source for those ad-icted to and seeking controlled substances is the ED.

DRUG-SEEKING BEHAVIOR

linicians have had great difficulty defining or accu-ately predicting those patients who present with facti-ious complaints to obtain opioid analgesics, either foralingering or diversion. Such “drug-seeking behaviors”

re poorly defined, arbitrary, and have many confound-rs, including the potential prejudices of the clinician. Inhe attempt to identify this set of patients, EPs have some-imes misapplied diagnostic tools intended to address non-rganic signs of pain. The utility of other tools to identifyon-organic pain sources, such as Waddell’s signs (e.g.,xial loading, distracted straight leg raise, pain on simulatedotation), have been questioned by subsequent literature andheir own original authors (9,10).

Although the identification of drug-seeking behavioray be controversial, it is more widely accepted that

hronic pain is epidemic in the United States. Frequently,hronic pain is associated with oligoanalgesia (inadequatelyreated pain), and in such cases patients often turn to emer-ency providers for acute supplementation of analgesics for

heir chronic pain. Such pseudo-addiction can be impossi- t

le to differentiate from true addiction. Chronic pain com-laints also are a frequently utilized symptom reportedrom those seeking opioids for malingering or diversion.ligoanalgesia, when considered as an individual diag-osis, can be a tremendous burden on the ED. Fre-uently, it is difficult to differentiate acute from chronicomplaints; technically speaking, time duration does notecessarily equate to acute or chronic classification, andany patients will describe chronic pain in acute terms

1). In our particular circumstance, our facilities becamenown in the region as destination sites for acquisition ofpioids, whether treating acute, chronic, acute-on-hronic, or factitious pain.

We found ourselves in this situation by following, inur clinical practice, the recommendations of the cur-ently dominant paradigm in pain treatment. This para-igm is described, for example, in one textbook by theollowing: “If the clinician is fooled and administers aarenteral opioid, it represents one consequence of hav-ng a humane approach to the treatment of acute pain.

hen writing prescriptions for oral opioids. . . if there issuspicion of opioid abuse. . . the number of pills shoulde limited and the drug that is most notorious for abuse,xycontin, should be avoided” (1, p. 2919). This recom-endation does not address the situation in which clini-

ians begin to feel they are being “fooled” on a frequentasis. With regard to distributing a “limited” number ofills, we found that our clinical encounters regularly degen-rated into debates about the number or type of pill to beispensed, with inevitable demands by patients to increasehe number, type, or strength of pill to be dispensed. Thesencounters left us feeling that, by addressing the issue usingague guidelines of “using caution” and “avoiding Oxycon-in,” we were not treating the true conditions afflicting ouratients. We were, instead, each entering into, withoutny institutional consistency, regular negotiations withatients who felt they had to manipulate us to get whathey felt they needed, whether for reasons of pain,alingering, or diversion.The Drug Enforcement Administration system exists

ot only to monitor the prescribing patterns of individualhysicians but also to provide a gateway to access habit-orming drugs. If we truly believe in the medical modelf addiction, we also must account for our actions inreating patients who are victims or at risk of becomingictims of this medical condition. In our community,here rates of prescription drug abuse and addiction

eemed very high relative to the communities in whiche had trained, all the abused drugs were, by definition,btained either directly from a provider or via diversion.f, therefore, we were to truly treat the community pan-emic of addiction, it would be necessary that we comep with more innovative ways to treat oligoanalgesia

han simply limiting the number of pills or injections we

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Chronic Pain and Drug-seeking Behavior 127

ffered. A substantial majority of our patients were alreadyeing treated with opioids by another provider, or had in theast, and had been released for non-compliance with con-racts. The policy of defaulting to small-dose opioidreatments frequently bypassed the arrangements andontracts a patient already had in place with anotherrovider. In aggregate, this could substantially—butairly invisibly—add to the community access, bypassinghe scrutiny of the Drug Enforcement Administration orrimary care providers.

AN ALTERNATE APPROACH

e felt a more discriminatory process was required toermit patients in acute pain to receive adequate analge-ia, and yet to manage the large volume of oligoanalge-ic, chronic, and acute-on-chronic patients in the ED. Welso felt a systematic approach was necessary to provideonsistency in our management. Multiple other authorsave proposed systematic tools to encourage providers toncrease analgesic use (11–14). Examples of protocolshat address potential drug-seeking behavior by system-tically limiting opioids for certain conditions, such asncomplicated dental pain, are more rare (15).

Demographically, we staff two EDs in a rural countyn the Southeast. This article addresses the experience ofur larger hospital, which has an average volume ofpproximately 36,000 patients a year. A task force wasssembled at this hospital consisting of nurses and EPs.ain Treatment Guidelines (Appendix) were developed

n an attempt to systematically manage patients withomplaints involving oligoanalgesic pain or pain withoutbjective findings. In addition, a system was put in place (aed dot on the chart) to flag those patients who were seenore than three times in the preceding 6 months. Thisarker was not meant to be pejorative, but instead to alertclinician to review past records for a patient whose com-laint might not otherwise precipitate a review of pastmergency records. It should be noted that these guidelinesontinue to permit clinicians to inject or prescribe anynalgesic deemed necessary in the treatment of acute pain.hey do, however, also offer a unified policy for managing

hose conditions without objective sign of injury, illness, orecent acuity that we (in contradiction to the prevailingodel) did not feel should be treated routinely with opioids.

n addition, as a group we do not refill or provide intervalupplementation of opioid or habit-forming prescriptionsritten by another physician, which is a prominent request

mong our patients. Patients are encouraged to utilize arimary care provider or pain clinic for ongoing manage-ent of chronic pain.This policy was approved by the Medical Executive

ommittee of our hospital and is supported by our local m

hysicians. The guidelines were implemented in August of003. Since then we have had no complaints from otherocal providers of inadequate emergent treatment of pain inur facilities, and all local physicians have cooperated withur initiative. In addition, a pain treatment center opened atne of our affiliated hospitals in September of 2005, andatients are now referred to these specialists if inadequatelyreated chronic pain is identified.

It should be noted that, although these guidelines areunctional for our community, they would certainly need toe adapted for others. For instance, we have an arrangementith our local primary care providers whereby patientsithout a primary care provider can be “assigned” off a

otating list for further stabilization and care. In areas wherehis is not feasible, or where patients rely solely on the EDor access to any sort of health care, clearly these guidelinesould have shortcomings. However, this would be true for

he management of all chronic conditions, not just non-cute pain conditions.

After implementation of these guidelines, there waso significant volume change compared to previousears. Subjectively, our perception is that we are seeingewer patients with suspected drug-seeking complaintsincluding headache, toothache, back pain, and flank painith alleged kidney stone.) Objectively, based on dis-

harge diagnoses provided by our billing company, theumber of patients we have diagnosed with idiopathiceadaches, toothaches, and back pain briefly declined buthen increased to levels higher than those seen before theuidelines (in both absolute numbers and relative to ourverall volume).

There could be many speculative interpretations ofur experience. Patients may feel more comfortable withhe guidelines and appreciate the clarity and reliabilityhis gives to their care. There may simply have been aigher incidence of these complaints in our communityfter the guidelines were implemented, by patients whoould have sought care regardless of our management

pproach. Either way, we as Emergency Physicians andurses feel much more comfortable managing these

omplaints with the guidelines, and feel the quality ofur management of patients in pain has improved. It alsoas been widely noted that job satisfaction and physicianorale has benefited from these guidelines.Our patients’ interpretation of the overall quality of

heir care also briefly decreased, and then steadily in-reased to levels equal or superior to pre-guideline val-es after the implementation of the pain guidelines wheneasured via patient satisfaction surveys routinely used

y our department’s administrators. In addition, whenpecifically asked about “effectiveness of pain manage-ent,” patients seemed to be more satisfied by their pain

anagement after implementation of the guidelines.

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128 S. C. Hawkins et al.

Again, multiple speculative explanations can be of-ered for this. Patients who feel they require opioids forhronic pain may no longer be presenting to our EDs;owever, any such migration of patients did not seem toffect our overall or relative volume. It could be arguedhat fewer of these patients presented because they noonger received appropriate pain treatment in the EDetting. However, that begs the underlying philosophicaluestion driving this discussion: is short-term manage-ent with opioids of apparently non-acute or acute-on-

hronic conditions appropriate treatment? In our com-unity we have found that it probably is not.

PAIN MANAGEMENT STUDIES:PHILOSOPHY VS. SCIENCE

he treatment of patients with oligoanalgesia and poten-ial drug-seeking behavior is not well studied. Numeri-ally, most oligoanalgesic pain patients will be seen by aommunity EP, and yet this type of provider-patientnterface is the least well-represented in those studieshat have been done. In a problem plaguing Emergency

edicine science in general, studies of other populationssuch as inpatients) are applied indiscriminately to Emer-ency Medicine populations. So, for example, the Bostonrug Collaborative Study (which is now a quarter cen-

ury old, and showed that only 4 of 11,892 inpatientsreated with opioids developed new opioid abuse) isrequently cited to support opioid use for acute pain (16).his ignores a number of critical questions:

. Are hospitalized patients comparable to patients beingdischarged from the ED?

. How many EPs routinely screen for addiction histo-ries in their evaluations, or routinely consider with-holding opioids for patients with alcohol or drugabuse history? The study assumed exclusion of pa-tients with prior history of addiction.

. Although addiction may not be demonstrated in thepatients themselves, in the context of diversion, howmany cases of addiction are initiated or perpetuatedby emergency administration of opioids?

What appears, then, is that although we know we muste concerned for opioid abuse, we do not have goodcience behind who we should withhold opioids from,or what the consequences are if they are not withheldut are prescribed with little discrimination. In the ab-ence of this, philosophical and moral recommendationsust take the place of evidence, as in the recommenda-

ion that a “humane approach” to treating purportedly

cute pain most often requires opioids.

CONCLUSION

t might be easy to interpret our experience and discussions an exhortation for the EP to withhold opioids. It is not. Itoes seem, however, that the current approach to managingligoanalgesia and chronic pain in Emergency Medicine isdentical to that of acute pain: treat the pain the patientescribes, regardless of clinical estimation of pain level orommunity prevalence of abuse, with the mainstay of treat-ent being opioids. This approach, we would argue, is

ased as much or more on philosophy as on medical sciencend research. Philosophical and moral compulsions in med-cal practice do not deserve less consideration simply be-ause they are not backed by data; however, due to the lackf evidence, they benefit even more from robust discussionnd the sharing of multiple experiences and perspectives.e suspect that a more discriminatory opioid treatment

pproach might be as or more appropriate in certain com-unities and practices. Current literature, however, is silent

s to what these approaches might be. In this article weropose one such intervention and discuss its perceivedesults. In addition, other innovative ways to manage oli-oanalgesic or drug-seeking patients exist: inter-facilityommunication, maintenance of patient logs, flags onharts, or contracts. However, aside from brief references,here is little discussion in the literature regarding actualmplementation of these tools. We hope that further caseeports and, ideally, more formal studies will continue todd to the mechanisms we use to provide the best and mostppropriate care to our patients with under-treated orhronic pain.

In terms of our practice, we found that implementingain treatment guidelines that restricted opioid use was notssociated with a decrease in patient volume and seemed toe associated with an increase in overall patient satisfaction,nd patient satisfaction with pain management. Physicianorale and job satisfaction also were substantially im-

roved after implementation of these guidelines.

REFERENCES

1. Paris P. Pain management. In: Marx JA, ed. Rosen’s emergencymedicine, 6th edn. St. Louis: Mosby; 2006:2913–37.

2. Ducharme J. Emergency pain management: a Canadian Associa-tion of Emergency Physicians (CAEP) consensus document.J Emerg Med 1994;12:855–66.

3. Guru V, Dubinsky I. The patient vs. caregiver perception of acutepain in the emergency department. J Emerg Med 2000;18:7–12.

4. Singer AJ, Gulla J, Thode HC. Parents and practitioners are poor judgesof young children’s pain severity. Acad Emerg Med 2002;9:609–12.

5. Drayer RA, Henderson J, Reidenberg M. Barriers to better pain control inhospitalized patients. J Pain Symptom Manage 1999;17:434–40.

6. Mantyselka P, Kumpusalo E, Ahonen R, Takala J. Patients’ versusgeneral practitioners’ assessments of pain intensity in primary carepatients with non-cancer pain. Br J Gen Pract 2001;51:995–7.

7. Owings JM. Pain management monograph not on the right track.ACEP News: December 2004.

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8. Bukata RW. Journal scan: retire the VAS score. Emerg Med NewsAugust 2005:6.

9. Waddell G, McCulloch JA, Kummel E, Venner RM. Nonorganicphysical signs in low-back pain. Spine 1980;5:117–25.

0. Main CJ, Waddell G. Behavioral responses to examination. Areappraisal of the interpretation of “nonorganic signs”. Spine 1998;23:2367–71.

1. American Pain Society Quality of Care Committee. Quality im-provement guidelines for the treatment of acute pain and cancerpain. JAMA. 1995;274:1874–80.

2. Ricard-Hibon A, Chollet C, Saada S, Loridant B, Marty J. Aquality control program for acute pain management in out-of-hospital critical medicine. Ann Emerg Med 1999;34:738–44.

3. Goodacre SW, Roden RK. A protocol to improve analgesia use inthe accident and emergency department. J Accid Emerg Med1996;13:177–9.

4. Jones JB. Assessment of pain management skills in emergencymedicine residents: the role of a pain education program. J EmergMed 1999;17:349–54.

5. Ma M. Effect of education and guidelines for treatment of uncom-plicated dental pain on patient and provider behavior. Ann EmergMed 2004;44:323–9.

6. Porter J, Jick H. Addiction rare in patients treated with narcotics.N Engl J Med 1980;302:123.

APPENDIX

lue Ridge HealthCare Pain Treatment Guidelines

bjective: To appropriately relieve pain for patients andttempt to identify those who may be abusing or addictedo narcotics and refer them for special assistance.

All patients with a complaint of pain will be providedith a screening examination and treatment.Guidelines: Access Management will screen all new

D patients for prior visits. Those patients with four orore visits in the last six months will have their chartagged so the ED physician can review their old records.ll patients with a complaint of acute or chronic painill receive an appropriate history and physical exami-ation. Previous tests and diagnostic studies will beeviewed. Physicians are to order additional tests ortudies if needed to confirm a diagnosis.

Patients who return multiple times with the same com-laint will be required to establish a relationship with anttending physician. The attending physician will help de-elop an acceptable treatment plan including type, route andrequency of medication to be used for treating the patient’sain in the ED. These guidelines will be kept on file in thehysician’s office and be shared between both Blue RidgeealthCare hospitals. If the treatment plan does not fitithin these guidelines it will have to be approved byountain Emergency Physicians.Witnessed urine drug screens may be done on any

atient complaining of pain and a sign will be posted inriage to inform patients of this policy. No narcotics orood-altering medication will be given to any patient

esting positive for a drug that they were not prescribed.

Medication allergies listed by the patients will be reviewedlong with previous ED visits and medications given on thoseisits. Physicians may treat with medication if they feel theeported reaction is not a true allergy. This deviation will beocumented in the patient’s record. The patient will be mon-tored for any signs or symptoms of a true allergic reaction.

These guidelines will be used by Mountain Emer-ency Physicians at Blue Ridge HealthCare hospitals inurke County. Patients with addictive behavior will be

eferred to their Physician or Foothills Mental Health/oothills Detoxification Center/Good Samaritan Clinic.

Narcotics use is justified for obvious illness/injury oronfirmed positive findings.

Treatments to be used following H&P and diagnosticesting [without positive findings]:

● Headache:1) The ED will not give patients IM narcotic injec-

tions for headaches (a sign will be available in Triageinforming patients of this.) IV medications may beused if a patient fails to respond to other treatments.

2) Alternatives include: Toradol, Reglan, Phener-gan, Compazine, DHE, Imitrex, Benadryl, Li-docaine, Caffeine, Decadron, Ultram, Ultracet,Darvocet, and non-narcotic oral medications.

3) Patients receiving IV medications will be ob-served at least 20 minutes to reassess pain relief.

● Alleged Kidney Stone:1) Alternatives include: Toradol, Phenergan, Dec-

adron, Procardia, Ultram, Ultracet, Darvocet,and non-narcotic oral medications.

2) Oral narcotic medications will not be prescribedwithout a positive finding, confirming diagnosis.

● Back Pain:1) Alternatives include: NSAIDs, steroids, Ultram, Ul-

tracet, Darvocet, and muscle relaxers (no Soma).2) Patients with repeated visits with this complaint

will be referred to a primary care physician ororthopedic physician for follow-up.

3) For true musculoskeletal pain consider referralto physical therapy.

● Toothache:1) Alternatives include: NSAIDs, Ultram, Ultracet,

Darvocet, antibiotics, and local nerve blocks.

● Chronic/Other Pain:1) Alternatives include: NSAIDs, Reglan, Phener-

gan, Ultram, Ultracet, Darvocet, and non-nar-cotic oral medications.

2) Patients with known chronic condition, or fouror more visits to the ED within the last sixmonths with the same or related complaint, willbe referred to their attending physician or as-

signed one using the current ED call schedule.