Emergency management of chronic pain and drug-seeking behavior: an alternate perspective

Refusal of emergency medical care: An analysis of patients who left without being seen, eloped, and left against medical advice

OBJECTIVE

Emergency department (ED) patients may elect to refuse any aspect of medical care. They may leave prior to physician evaluation, elope during treatment, or leave against medical advice during treatment. This study was undertaken to identify patient perspectives and reasons for refusal of care.

METHODS

This prospective study was conducted at an urban Level 1 Trauma Center. This study examined ED patients who left without being seen (LWBS), eloped during treatment, or left against medical advice during September to December 2018. This project included both chart review and a prospective patient survey.

RESULTS

Among 298 participants, the majority were female (54%). Most participants were White (61%) or African American (36%). Thirty-eight percent of participants left against medical advice, 23% eloped, and 39% left without being seen by a provider. When compared to the general ED population, patients who refused care were significantly younger (p < 0.001). When comparing by groups, patients who left AMA were significantly older than those who eloped or left without being seen (p < 0.001). Among 68 patients interviewed by telephone, the most common stated reasons for refusal of care included wait time (23%), unmet expectations (23%), and negative interactions with ED staff (15%).

CONCLUSION

ED patients who refused care were significantly younger than the general ED population. Common reasons cited by patients for refusal of care included wait time, unmet expectations, and negative interactions with ED staff.

Patient Satisfaction Surveys in the Outpatient Clinic Setting: The Variability of Response With Positively or Negatively Toned Questions

The purpose of this study was to determine whether a patient satisfaction survey in the outpatient clinic setting using questions with either a positive or negative tone would produce consistent responses. This was a prospective study using a 20-question paper survey delivered to medical students who were asked to rate on a scale of 1 to 10 to what degree they either agree or disagree with statements regarding their most recent personal outpatient clinic health care visit (any medical specialty). The same survey was administered again through an e-mail link 1 week later. One hundred fifty (77%) students completed the 20-item survey and 53 (35%) of the participating students completed the follow-up e-mail survey. Seven of the 10 question pairs on the paper survey revealed statistically significant differences in responses based on tone, with greater values for disagreement with negatively toned questions than values representing agreement with positive-toned questions. The match rates for similar questions posed on the paper survey and then the e-mail survey 1 week later ranged between 27.8% and 56.6%. This study demonstrated that, with an outpatient health care patient satisfaction survey, disagreement with a negative-toned question was stronger than agreement with a positive-toned question. There was poor correlation between survey responses when first posed on a paper survey and then repeated on a digital survey 1 week later. These findings suggest that the wording of survey questions may affect responses and that survey answers change with time and across delivery platforms.

Effect Of A "No Superuser Opioid Prescription" Policy On ED Visits And Statewide Opioid Prescription

INTRODUCTION

The U.S. opioid epidemic has highlighted the need to identify patients at risk of opioid abuse and overdose. We initiated a novel emergency department- (ED) based interventional protocol to transition our superuser patients from the ED to an outpatient chronic pain program. The objective was to evaluate the protocol's effect on superusers' annual ED visits. Secondary outcomes included a quantitative evaluation of statewide opioid prescriptions for these patients, unique prescribers of controlled substances, and ancillary testing.

METHODS

Patients were referred to the program with the following inclusion criteria: ≥ 6 visits per year to the ED; at least one visit identified by the attending physician as primarily driven by opioid-seeking behavior; and a review by a committee comprising ED administration and case management. Patients were referred to a pain management clinic and informed that they would no longer receive opioid prescriptions from visits to the ED for chronic pain complaints. Electronic medical record (EMR) alerts notified ED providers of the patient's referral at subsequent visits. We analyzed one year of data pre- and post-referral.

RESULTS

A total of 243 patients had one year of data post-referral for analysis. Median annual ED visits decreased from 14 to 4 (58% decrease, 95% CI [50 to 66]). We also found statistically significant decreases for these patients' state prescription drug monitoring program (PDMP) opioid prescriptions (21 to 13), total unique controlled-substance prescribers (11 to 7), computed tomography imaging (2 to 0), radiographs (5 to 1), electrocardiograms (12 to 4), and labs run (47 to 13).

CONCLUSION

This program and the EMR-based alerts were successful at decreasing local ED visits, annual opioid prescriptions, and hospital resource allocation for this population of patients. There is no evidence that these patients diverted their visits to neighboring EDs after being informed that they would not receive opioids at this hospital, as opioid prescriptions obtained by these patients decreased on a statewide level. This implies that individual ED protocols can have significant impact on the behavior of patients.

Racial-Ethnic Disparities in Opioid Prescriptions at Emergency Department Visits for Conditions Commonly Associated with Prescription Drug Abuse

Prescription drug abuse is a growing problem nationally. In an effort to curb this problem, emergency physicians might rely on subjective cues such as race-ethnicity, often unknowingly, when prescribing opioids for pain-related complaints, especially for conditions that are often associated with drug-seeking behavior. Previous studies that examined racial-ethnic disparities in opioid dispensing at emergency departments (EDs) did not differentiate between prescriptions at discharge and drug administration in the ED. We examined racial-ethnic disparities in opioid prescription at ED visits for pain-related complaints often associated with drug-seeking behavior and contrasted them with conditions objectively associated with pain. We hypothesized a priori that racial-ethnic disparities will be present among opioid prescriptions for conditions associated with non-medical use, but not for objective pain-related conditions. Using data from the National Hospital Ambulatory Medical Care Survey for 5 years (2007-2011), the odds of opioid prescription during ED visits made by non-elderly adults aged 18-65 for 'non-definitive' conditions (toothache, back pain and abdominal pain) or 'definitive' conditions (long-bone fracture and kidney stones) were modeled. Opioid prescription at discharge and opioid administration at the ED were the primary outcomes. We found significant racial-ethnic disparities, with non-Hispanic Blacks being less likely (adjusted odds ratio ranging from 0.56-0.67, p-value < 0.05) to receive opioid prescription at discharge during ED visits for back pain and abdominal pain, but not for toothache, fractures and kidney stones, compared to non-Hispanic whites after adjusting for other covariates. Differential prescription of opioids by race-ethnicity could lead to widening of existing disparities in health, and may have implications for disproportionate burden of opioid abuse among whites. The findings have important implications for medical provider education to include sensitization exercises towards their inherent biases, to enable them to consciously avoid these biases from defining their practice behavior.

Impact of a Chronic Pain Protocol on Emergency Department Utilization

OBJECTIVES

Patients suffering from chronic painful conditions frequently present to the emergency department (ED) for pain control. In an effort to better manage these patients we implemented and measured the effect of enrollment in a chronic pain protocol in a single ED.

METHODS

A retrospective (pre) and prospective (post) study design was utilized. We identified 46 frequent ED users suffering from chronic painful conditions. We then retrospectively documented their ED use and prescription controlled substance use for 6 months prior to enrollment in a chronic pain protocol and then 6 months postenrollment.

RESULTS

Preenrollment participating patients visited the ED on average 6.2 times in a 6-month period. Postenrollment their mean number of visits in the following 6 months decreased significantly to 2.2 times, or a 65% decrease (p < 0.001). Similarly, preenrollment, the patients were prescribed a median of 664 controlled substance pills in the entire state compared to 471 pills in the 6-month period postenrollment, or a 29% decrease (p < 0.022).

CONCLUSIONS

Through instituting a chronic pain protocol, we found significant reductions in the number of return visits to a single ED and the number of controlled substance medications prescribed by all providers. Additional studies using similar protocols could help establish their impact on the care of patients suffering from chronic pain and the potential to reduce healthcare costs, ED overcrowding, and prescription drug abuse.

Model determination of delayed causes of analgesics prescription in the emergency ward in arak, iran

Background

According to the reports of the World Health Organization 20% of world population suffer from pain and 33% of them suffer to some extent that they cannot live independently.

Methods

This is a cross-sectional study which was conducted in the emergency department (ED) of Valiasr Hospital of Arak, Iran, in order to determine the causes of delay in prescription of analgesics and to construct a model for prediction of circumstances that aggravate oligoanalgesia. Data were collected during a period of 7 days.

Results

Totally, 952 patients participated in this study. In order to reduce their pain intensity, 392 patients (42%) were treated. Physicians and nurses recorded the intensity of pain for 66.3% and 41.37% of patients, respectively. The mean (SD) of pain intensity according to visual analogue scale (VAS) was 8.7 (1.5) which reached to 4.4 (2.3) thirty minutes after analgesics prescription. Median and mean (SD) of delay time in injection of analgesics after the physician's order were 60.0 and 45.6 (63.35) minutes, respectively. The linear regression model suggested that when the attending physician was male or intern and patient was from rural areas the delay was longer.

Conclusions

We propose further studies about analgesics administration based on medical guidelines in the shortest possible time and also to train physicians and nurses about pain assessment methods and analgesic prescription.

How do emergency physicians interpret prescription narcotic history when assessing patients presenting to the emergency department with pain?

CONTEXT

Narcotics are frequently prescribed in the Emergency Department (ED) and are increasingly abused. Prescription monitoring programs affect prescribing by Emergency Physicians (EPs), yet little is known on how EPs interpret prescription records.

OBJECTIVE

To assess how EPs interpret prescription narcotic history for patients in the ED with painful conditions. DESIGN/MAIN Outcome Measures: We created an anonymous survey of EPs consisting of fictitious cases of patients presenting to the ED with back pain. For each case, we provided a prescription history that varied in the number of narcotic prescriptions, prescribing physicians, and narcotic potency. Respondents rated how likely they thought each patient was drug seeking, and how likely they thought that the prescription history would change their prescribing behavior. We calculated κ values to evaluate interobserver reliability of physician assessment of drug-seeking behavior.

RESULTS

We collected 59 responses (response rate = 70%). Respondents most suspected drug seeking in patients with greater than 6 prescriptions per month or greater than 6 prescribing physicians in 2 months. Medication potency did not affect physician interpretation of drug seeking. Respondents reported that access to a prescription history would change their prescribing practice in all cases. κ values for assessment of drug seeking demonstrated moderate agreement.

CONCLUSION

A greater number of prescriptions and a greater number of prescribing physicians in the prescription record increased suspicion for drug seeking. EPs believed that access to prescription history would change their prescribing behavior, yet interobserver reliability in the assessment of drug seeking was moderate.

How Frequently are "Classic" Drug-Seeking Behaviors Used by Drug-Seeking Patients in the Emergency Department?

Introduction:

Drug-seeking behavior (DSB) in the emergency department (ED) is a very common problem, yet there has been little quantitative study to date of such behavior. The goal of this study was to assess the frequency with which drug seeking patients in the ED use classic drug seeking behaviors to obtain prescription medication.

Methods:

We performed a retrospective chart review on patients in an ED case management program for DSB. We reviewed all visits by patients in the program that occurred during a 1-year period, and recorded the frequency of the following behaviors: complaining of headache, complaining of back pain, complaining of dental pain, requesting medication by name, requesting a refill of medication, reporting medications as having been lost or stolen, reporting 10/10 pain, reporting greater than 10/10 pain, reporting being out of medication, and requesting medication parenterally. These behaviors were chosen because they are described as “classic” for DSB in the existing literature.

Results:

We studied 178 patients from the case management program, who made 2,486 visits in 1 year. The frequency of each behavior was: headache 21.7%, back pain 20.8%, dental pain 1.8%, medication by name 15.2%, requesting refill 7.0%, lost or stolen medication 0.6%, pain 10/10 29.1%, pain greater than 10/10 1.8%, out of medication 9.5%, and requesting parenteral medication 4.3%. Patients averaged 1.1 behaviors per visit.

Conclusion:

Drug-seeking patients appear to exhibit “classically” described drug-seeking behaviors with only low to moderate frequency. Reliance on historical features may be inadequate when trying to assess whether or not a patient is drug-seeking.

The role of the emergency department in the acute management of chronic or recurrent pain

BACKGROUND

Exacerbation of chronic pain is a common presenting problem for patients attending emergency departments (EDs), with many making multiple visits.

AIM

This paper aims to identify the role of the ED in the acute management of patients with persistent or chronic nonmalignant pain through a review of current literature.

METHOD

Four databases were searched using the MeSH and subject search terms "chronic nonmalignant pain", "persistent pain" and "emergency" and synonyms associated with these terms. Literature related to the underlying causes of suboptimal chronic pain management along with the sequelae associated with treatment or management was extracted.

RESULTS

Three main themes emerged: patient expectations and satisfaction, barriers to care, and strategies/principles to improve ED management for this patient group. The presence of these themes appears to be partially due to time limitations for chronic issues in an acute department, accompanied by a lack of clear guidelines.

CONCLUSION

It is evident that the ED is not the ideal setting for managing patients with chronic pain however it is the last resort for many who do present, and who will continue to present should their pain persist. It is time to ensure that the ED provides a consistently supportive, cohesive and integrated approach to managing patients with chronic pain syndromes.