Keeping lists and naming names: habitual patient files for suspected nontherapeutic drug-seeking patients

Cross-Cultural Validation of the English Chronic Pain Myth Scale in Emergency Nurses

Background

Utilization of the emergency department (ED) by patients seeking relief from chronic pain (CP) has increased. These patients often face stigmatization, and the ED is no exception. The French-Canadian Chronic Pain Myth Scale (CPMS) was developed to evaluate common societal misconceptions about CP including among healthcare providers. To our knowledge, no tool of this nature is available in English.

Objectives

This study thus aimed at determining to what extent a new English adaptation of the CPMS could provide valid scores among US emergency nurses. The internal consistency, construct validity, and internal structure of the translated scale were thus examined.

Methods

After careful translation of the scale, the English CPMS was administered to 482 emergency nurses and its validity was explored through a web-based cross-sectional study.

Results

Acceptable reliability (α > 0.7) was reported for the first and third subscales. The second subscale's reliability coefficient was below the cutoff (α=0.67) but is still considered adequate. As expected, statistically significant differences were found between nurses suffering from CP vs nurses not suffering from CP, supporting the construct validity of the scale. After exploratory factor analysis, similar internal structure was found supporting the 3-factorial nature of the original CPMS.

Conclusion

Our results provide support for the preliminary validity of the English CPMS to measure knowledge, beliefs, and attitudes towards CP among emergency nurses in the United States.

Knowledge, Beliefs, and Attitudes of Emergency Nurses Toward People With Chronic Pain

More and more people suffering from chronic pain (CP) utilize the emergency department (ED). However, their needs are not properly addressed. Stigmatization toward people with CP can partially explain this gap. Most studies in the ED have been focused on measuring nurses' pain management knowledge in general, not negative attitudes toward CP. Hence, understanding of the determinants of the stigma related to CP is needed. The objectives of this study were to (a) describe the knowledge, beliefs, and attitudes of ED nurses toward people suffering from CP and (b) identify nurses' characteristics associated with these perceptions. A cross-sectional web-based survey design was conducted using the KnowPain-12 questionnaire and the Chronic Pain Myth Scale. A total of 571 participants from 20 different states across the United States were recruited among whom 482 completed the entire survey. The sample included about one third of the ED nurses suffering from CP. Negative beliefs and attitudes toward people with CP were present in a considerable proportion of participants (up to 64%), even in nurses suffering from CP (up to 47.5%). Nevertheless, our results suggest that higher levels of education and suffering from CP were associated with better beliefs and attitudes toward people with CP. The ED presents an increased risk of stigmatization of people with CP as compared with the general population. Identifying determinants of the stigma associated with CP is crucial, as it will help tailoring awareness and educational campaigns. In addition, CP patients utilizing the ED often have complex needs which are difficult to address in this clinical environment. This situation can contribute to negative beliefs and attitudes. Given the scarcity of specialized care clinics for this population, health-care stakeholders should devise solutions to improve continuity of care in primary care settings and between the latter and ED.

Effect of Automated Prescription Drug Monitoring Program Queries on Emergency Department Opioid Prescribing

STUDY OBJECTIVE

We assess whether an automated prescription drug monitoring program intervention in emergency department (ED) settings is associated with reductions in opioid prescribing and quantities.

METHODS

We performed a retrospective cohort study of ED visits by Medicaid beneficiaries. We assessed the staggered implementation (pre-post) of automated prescription drug monitoring program queries at 86 EDs in Washington State from January 1, 2013, to September 30, 2015. The outcomes included any opioid prescribed within 1 day of the index ED visit and total dispensed morphine milligram equivalents. The exposure was the automated prescription drug monitoring program query intervention. We assessed program effects stratified by previous high-risk opioid use. We performed multiple sensitivity analyses, including restriction to pain-related visits, restriction to visits with a confirmed prescription drug monitoring program query, and assessment of 6 specific opioid high-risk indicators.

RESULTS

The study included 1,187,237 qualifying ED visits (898,162 preintervention; 289,075 postintervention). Compared with the preintervention period, automated prescription drug monitoring program queries were not significantly associated with reductions in the proportion of visits with opioid prescribing (5.8 per 1,000 encounters; 95% confidence interval [CI] -0.11 to 11.8) or the amount of prescribed morphine milligram equivalents (difference 2.66; 95% CI -0.15 to 5.48). There was no evidence of selective reduction in patients with previous high-risk opioid use (1.2 per 1,000 encounters, 95% CI -9.5 to 12.0; morphine milligram equivalents 1.22, 95% CI -3.39 to 5.82). The lack of a selective reduction in high-risk patients was robust to all sensitivity analyses.

CONCLUSION

An automated prescription drug monitoring program query intervention was not associated with reductions in ED opioid prescribing or quantities, even in patients with previous high-risk opioid use.

Impact of Hospital "Best Practice" Mandates on Prescription Opioid Dispensing After an Emergency Department Visit

OBJECTIVE

Washington State mandated seven hospital "best practices" in July 2012, several of which may affect emergency department (ED) opioid prescribing and provide a policy template for addressing the opioid prescription epidemic. We tested the hypothesis that the mandates would reduce opioid dispensing after an ED visit. We further assessed for a selective effect in patients with prior risky or chronic opioid use.

METHODS

We performed a retrospective, observational analysis of ED visits by Medicaid fee-for-service beneficiaries in Washington State, between July 1, 2011, and June 30, 2013. We used an interrupted time-series design to control for temporal trends and patient characteristics. The primary outcome was any opioid dispensing within 3 days after an ED visit. The secondary outcome was total morphine milligram equivalents (MMEs) dispensed within 3 days.

RESULTS

We analyzed 266,614 ED visits. Mandates were associated with a small reduction in opioid dispensing after an ED visit (-1.5%, 95% confidence interval [CI] = -2.8% to -0.15%). The mandates were associated with decreased opioid dispensing in 42,496 ED visits by patients with prior risky opioid use behavior (-4.7%, 95% CI = -7.1% to -2.3%) and in 20,238 visits by patients with chronic opioid use (-3.6%, 95% CI = -5.6% to -1.7%). Mandates were not associated with reductions in MMEs per dispense in the overall cohort or in either subgroup.

CONCLUSIONS

Washington State best practice mandates were associated with small but nonselective reductions in opioid prescribing rates. States should focus on alternative policies to further reduce opioid dispensing in subgroups of high-risk and chronic users.

A Randomized Controlled Trial of a Citywide Emergency Department Care Coordination Program to Reduce Prescription Opioid Related Emergency Department Visits

BACKGROUND

Increasing prescription overdose deaths have demonstrated the need for safer emergency department (ED) prescribing practices for patients who are frequent ED users.

OBJECTIVES

We hypothesized that the care of frequent ED users would improve using a citywide care coordination program combined with an ED care coordination information system, as measured by fewer ED visits by and decreased controlled substance prescribing to these patients.

METHODS

We conducted a multisite randomized controlled trial (RCT) across all EDs in a metropolitan area; 165 patients with the most ED visits for complaints of pain were randomized. For the treatment arm, drivers of ED use were identified by medical record review. Patients and their primary care providers were contacted by phone. Each patient was discussed at a community multidisciplinary meeting where recommendations for ED care were formed. The ED care recommendations were stored in an ED information exchange system that faxed them to the treating ED provider when the patient presented to the ED. The control arm was subjected to treatment as usual.

RESULTS

The intervention arm experienced a 34% decrease (incident rate ratios = 0.66, p < 0.001; 95% confidence interval 0.57-0.78) in ED visits and an 80% decrease (odds ratio = 0.21, p = 0.001) in the odds of receiving an opioid prescription from the ED relative to the control group. Declines of 43.7%, 53.1%, 52.9%, and 53.1% were observed in the treatment group for morphine milligram equivalents, controlled substance pills, prescriptions, and prescribers, respectively.

CONCLUSION

This RCT showed the effectiveness of a citywide ED care coordination program in reducing ED visits and controlled substance prescribing.

Interpreting the National Hospital Ambulatory Medical Care Survey: United States Emergency Department Opioid Prescribing, 2006-2010

OBJECTIVES

Prescription opioid overdoses are a leading cause of death in the United States. Emergency departments (EDs) are potentially high-risk environments for doctor shopping and diversion. The hypothesis was that opioid prescribing rates from the ED have increased over time.

METHODS

The authors analyzed data on ED discharges from the 2006 through 2010 NHAMCS, a probability sample of all U.S. EDs. The outcome was documentation of an opioid prescription on discharge. The primary independent predictor was time. Covariates included severity of pain, a pain-related discharge diagnosis, age, sex, race, payer, hospital ownership, and geographic location of hospital. Up to three discharge diagnoses were available in NHAMCS to identify "pain-related" (e.g., back pain, fracture, dental/jaw pain, nephrolithiasis) ED visits. Multivariate logistic regression was performed to assess the independent associations between opioid prescribing and predictors. All analyses incorporated NHAMCS survey weights, and all results are presented as national estimates.

RESULTS

Opioids were prescribed for 18.7% (95% confidence interval = 17.7% to 19.7%) of all ED discharges, representing 18.8 million prescriptions per year. There were no significant temporal trends in opioid prescribing overall (adjusted p = 0.93). Pain-related discharge diagnoses that received the top three highest proportion of opioids prescriptions included nephrolithiasis (62.1%), neck pain (51.6%), and dental/jaw pain (49.7%). A pain-related discharge diagnosis, non-Hispanic white race, older age, male sex, uninsured status, and Western region were positively associated with opioid prescribing (p < 0.05).

CONCLUSIONS

No temporal trend toward increased prescribing from 2006 to 2012 was found. These results suggest that problems with opioid overprescribing are multifactorial and not solely rooted in the ED.

Care plans reduce ED visits in those with drug-seeking behavior

Patients with drug-seeking behavior can be both labor and resource intensive to the emergency department (ED).

OBJECTIVE

To determine the effectiveness of ED care plans for individuals at high risk for drug-seeking behavior on ED visits.

METHODS

A retrospective, cohort observational study.

LOCATION

A suburban teaching hospital with an annual census of 80,000 patients. The number of ED visits was determined 1 year before and 2 subsequent years following care plan initiation.

EXCLUSION CRITERIA

Unclaimed letter, incomplete data, and/or non-drug-seeking care plan.

STATISTICS

Two-tailed Wilcoxon signed-rank test with significance of P < .05.

RESULTS

Sixty patients were enrolled and 7 were excluded, leaving 53 patients for analysis. Mean annual visits before care plan initiation were 7.6 (95% confidence interval [CI], 6.3-9.1). One year following implementation, mean visits decreased to 2.3 (95% CI, 1.5-3.1) (P ≤ .0001). Two years following implementation, mean visits continued to decline to 1.5 (95% CI, 0.9-2.1) (P ≤ .0001). A significant reduction in visits occurred 1 and 2 years following care plan implementation.

CONCLUSIONS

Emergency department care plans are an effective method to reduce ED visits in those with drug-seeking behavior.

Rising opioid prescribing in adult U.S. emergency department visits: 2001-2010

OBJECTIVES

The objective was to describe trends in opioid and nonopioid analgesia prescribing for adults in U.S. emergency departments (EDs) over the past decade.

METHODS

Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2001 through 2010 were analyzed. ED visits for adult patients (≥18 years of age) during which an analgesic was prescribed were included. Trends in the use of six commonly prescribed opioids, stratified by Drug Enforcement Agency (DEA) schedule, as well as nonopioid analgesics were explored, along with the frequency of pain-related ED visits. For 2005 through 2010, data were further divided by whether the opioid was administered in the ED versus prescribed at discharge.

RESULTS

Between 2001 and 2010, the percentage of overall ED visits (pain-related and non-pain-related) where any opioid analgesic was prescribed increased from 20.8% to 31.0%, an absolute increase of 10.2% (95% confidence interval [CI] = 7.0% to 13.4%) and a relative increase of 49.0%. Use of DEA schedule II analgesics increased from 7.6% in 2001 to 14.5% in 2010, an absolute increase of 6.9% (95% CI = 5.2% to 8.5%) and a relative increase of 90.8%. Use of schedule III through V agents increased from 12.6% in 2001 to 15.6% in 2010, an absolute increase of 3.0% (95% CI = 2.0% to 5.7%) and a relative increase of 23.8%. Prescribing of hydrocodone, hydromorphone, morphine, and oxycodone all increased significantly, while codeine and meperidine use declined. Prescribing of nonopioid analgesics was unchanged, 26.2% in 2001 and 27.3% in 2010 (95% CI = -1.0% to 3.4%). Hydromorphone and oxycodone had the greatest increase in ED administration between 2005 and 2010, while oxycodone and hydrocodone had the greatest increases in discharge prescriptions. There was no difference in discharge prescriptions for nonopioid analgesics. The percentage of visits for painful conditions during the period increased from 47.1% in 2001 to 51.1% in 2010, an absolute increase of 4.0% (95% CI = 2.3% to 5.8%).

CONCLUSIONS

There has been a dramatic increase in prescribing of opioid analgesics in U.S. EDs in the past decade, coupled with a modest increase in pain-related complaints. Prescribing of nonopioid analgesics did not significantly change.

Depression and pain interference among patients with chronic pain after ED encounters

INTRODUCTION

Patients with chronic pain who frequent emergency departments present a challenge to health care providers. Mental health, substance abuse, and pain issues are difficult to distinguish in fast-paced clinical settings, and significant symptoms may remain unaddressed. This pilot study sought to determine whether electronically delivered screening tools measuring pain and mood could identify areas to target for improving emergency care.

METHODS

A prospective, descriptive pilot study used repeated measures of validated instruments to investigate the status of patients after their ED encounter. Persons with chronic pain not related to cancer and documented opioid use were recruited by nursing personnel after an ED encounter. Consenting participants (n = 52) were invited to perform an online survey that included self-reported measurements of pain intensity, pain interference, depression, subjective health, and health distress. The survey was repeated after 8 weeks.

RESULTS

The baseline survey was completed by 42.3% of 52 patients who provided consent (n = 22, 68.2% female). The mean pain severity score was 5.96 (SD 1.57) and the mean pain interference score was 7.52 (SD 1.81) using 0 to 10 scales of the Brief Pain Inventory. Personal Health Questionnaire Depression Scale ratings indicated that a major depressive disorder should be considered for 54% of the participants.

DISCUSSION

Online surveys delivered to patients with chronic pain detected unmet needs for depression and persisting high levels of pain interference after ED encounters. Adding mood-specific screening tools to pain assessments may be necessary in clinical settings to identify depression and refer for appropriate treatment.

Revisiting sociotechnical systems in a case of unreported use of health information exchange system in three hospital emergency departments

BACKGROUND

Health information exchange (HIE) allows clinicians to access patient level health care information. HIE can potentially improve patient care in emergency departments.

METHODS

We present a selected piece of evaluation of an HIE implementation in three Midwestern emergency departments. Data were collected through over 210 hours of direct observations and short interviews with 13 clinicians.

RESULTS

The results suggest that the usage rate of the HIE was low. Moreover, two ways of unreported use of the HIE system by clinicians was uncovered: (1) The HIE system was being used mostly for patients only with specific characteristics. (2) The information from the HIE system could be used to confront with the patients.

DISCUSSION

This study provides a case of how social system may shape a HIE technology. In order to fully benefit from HIE, understanding organizational and social context during the HIE design and implementation is needed. Such an understanding will also allow us to identify and detail required additional resources and organizational interventions that will complement HIE such as a case management strategy.

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.

Intravenous Opioids for Severe Acute Pain in the Emergency Department

Objective:

To review clinical trials of intravenous opioids for severe acute pain in the emergency department (ED) and to provide an approach for optimization of therapy.

Data Sources:

Articles were identified through a search of Ovid/MEDLINE (1948-August 2010), PubMed (1950-August 2010), Cochrane Central Register of Controlled Trials (1991-August 2010), and Google Scholar (1900-August 2010). The search terms used were pain, opioid, and emergency department.

Study Selection and Data Extraction:

The search was limited by age group to adults and by publication type to comparative studies. Studies comparing routes of administration other than intravenous or using non-opioid comparators were not included. Bibliographies of all retrieved articles were reviewed to obtain additional articles. The focus of the search was to identify original research that compared intravenous opioids used for treatment of severe acute pain for adults in the ED.

Data Synthesis:

At equipotent doses, randomized controlled trials have not shown clinically significant differences in analgesic response or adverse effects between opioids studied. Single opioid doses less than 0.1 mg/kg of intravenous morphine, 0.015 mg/kg of intravenous hydromorphone, or 1 μg/kg of intravenous fentanyl are likely to be inadequate for severe, acute pain and the need for additional doses should be anticipated. In none of the randomized controlled trials did patients develop respiratory depression requiring the use of naloxone. Future trials could investigate the safety and efficacy of higher doses of opioids. Implementation of nurse-initiated and patient-driven pain management protocols for opioids in the ED has shown improvements in timely provision of appropriate analgesics and has resulted in better pain reduction.

Conclusions:

Currently, intravenous administration of opioids for severe acute pain in the ED appears to be inadequate. Opioid doses in the ED should be high enough to provide adequate analgesia without additional risk to the patient. EDs could implement institution-specific protocols to standardize the management of pain.

Hyper-use of the ED

OBJECTIVES

This study aims to describe the population that averages one or more emergency department (ED) visits per month and compare them to the general ED population to determine if there are associated characteristics.

METHODS

A retrospective cohort study conducted in a teaching hospital between January 1, 2001, and December 31, 2004, identified all patients with more than 35 visits. This hyper-user (HU) cohort (n = 49) was compared to a randomly selected group of non-HU patients (n = 50) on the following measures: age, sex, insurance coverage, primary medical doctor (PMD), dwelling location, chief complaint, comorbidities, and disposition.

RESULTS

The HU group was significantly older (mean, 49.45 years) than the non-HU group (37.32 years) with a P < .0001. There was no difference between the groups in sex, insurance coverage, PMD, dwelling location, and disposition. A univariant logistical regression found that previous cardiovascular, genitourinary, or psychiatric disease were predictors of hyper-use.

CONCLUSIONS

The HU group is older and more likely to have a history of cardiovascular, genitourinary, and psychiatric disease but is similar to the non-HU group in other measured parameters. The HU group appears to have equal access to a PMD and is not more likely to be admitted to the hospital than the non-HU group.

Development and Validation of a Low-Literacy Opioid Contract

Opioid contracts (OPCs) are often used to outline the criteria and circumstances for which opioid medications are prescribed. The purpose of this study was to develop and validate an English-language, low-literacy OPC. Specifically, the low-literacy OPC was designed to outline proper administration of prescribed medication(s) as well as highlight patient responsibilities and expectations. A 4-step process was used to develop and validate the low-literacy OPC, including: (1) content identification; (2) attention to low-literacy guidelines; (3) evaluation based on Suitability Assessment of Materials (SAM) criteria; and (4) pilot testing with patients (n = 18) to assess comprehension. Final OPC content, presented largely in bulleted format, was based on current literature and consensus of the first 3 authors. The 4-part OPC was formatted on 8(1/2) x 11 inch paper using 16- to 24-point size Arial-style font. The 6-page OPC, written at the 7(th) reading grade level, included 12 recognizable clipart-type illustrations to supplement written text. Two reviewers scored the OPC in the superior range based on total SAM percentage scores. Nineteen (n = 19) of the 26 statements were comprehended by all patients completing the pilot testing. Overall, the low-literacy OPC is comprehensive, valid, readable, and formatted according to established low-literacy guidelines.

PERSPECTIVE

This study describes the development and validation of a low-literacy, English-language OPC. The OPC was formatted using low-literacy guidelines and validated with a sample of patients to confirm understanding of content. Accordingly, the low-literacy OPC is suitable for use in routine clinical practice.

Privacy and confidentiality in emergency medicine: obligations and challenges

Respect for privacy and confidentiality have been professional responsibilities of physicians throughout recorded history. This article reviews the moral, religious, and legal foundations of privacy and confidentiality and discusses the distinction between these two closely related concepts. Current federal and state laws are reviewed, including HIPAA regulations and their implications for research and care in the emergency department. In the emergency department, privacy and confidentiality often are challenged by physical design, crowding, visitors, film crews, communication, and other factors. These problems are reviewed, and advice and guidelines are offered for helping preserve patients' dignity and rights to privacy and confidentiality.

Ethics and the law in emergency medicine

When ethical issues arise in emergency medical practice, many emergency physicians turn to the law for answers. Although knowing when and how the law applies to emergency medicine is important, the law is only one factor to consider among many factors. Additionally, the law may not be applicable or may not be clear, or the ethical considerations may seem to conflict with legal aspects of emergency medical treatment. Situations where ethics and the law may seem to be in conflict in emergency medicine are described and analyzed in this article, and recommendations are offered. In general, when facing ethical dilemmas in emergency medical practice, the emergency physician should take into account the ethical considerations before turning to the legal considerations.

Establishing an emergency department pain management system

Any ED system for the management of pain in the ED should consider the following: assessment of pain including mandatory use of some assessment tool, a guideline for treatment of pain, communication with other members of the health care team, assessment tools, program monitoring, and a continuous quality assurance program. The treatment guideline should consider acute versus chronic pain, potential medication tolerance, concurrent anxiety and psychiatric issues, special populations, and disease-specific conditions.

The drug-seeking patient in the emergency room

Drug-seeking patients include recreational drug abusers, addicts whose dependence occurred through abuse or the injudicious prescription of narcotics, and pseudoaddicts who have chronic pain that has not been appropriately managed. Opioids produce euphoria in some patients, providing the motivation for abuse, which can be detrimental even with occasional use. Even in the absence of overt euphoria, opioids are highly self-reinforcing and can be problematic in a large number of patients, requiring that acute care physicians exercise caution in whom they are administered. Habitual patient files, narcotic contracts, pain management letters, and patient tracking and management programs can be used for the benefit of both drug seeking-patients and chronic pain patients. For many patients, drug-seekers and chronic pain patients alike, withholding opioids may be an important part of their long-term management. For others, long-acting opioids such as long-acting morphine or methadone are a reasonable option.

Management of Chronic Pain in the Acute Care Setting

Chronic nonmalignant pain requires evaluation and treatment different from acute pain. The pathophysiology is different, and there is commonly some degree of psychosocial dysfunction. Opioids tend to be much less effective as analgesics for chronic pain, and may increase the sensitivity to pain when given long-term. Because they are self-reinforcing, opioids may be sought and be reported to improve chronic pain, even when they may make the condition worse over time. There are many effective alternatives to opioids for the treatment of chronic pain, but their use is complicated and may require considerable time and effort to determine which ones work. Patients, particularly those who have already been prescribed opioids, may resist these alternatives. An extensive physical and psychosocial evaluation is required in the management of chronic pain, which is difficult if not impossible to achieve in the emergency or urgent care settings. Consequently, emergency and urgent care physicians should work closely with the patient's pain management specialist or personal physician. Systems should be set up in advance to identify those patients whose frequent use of acute care services for obtaining opioids may be compromising their long-term management, putting themselves at risk for psychological and tolerance-induced adverse effects of frequent opioid use. Opioids may be used in carefully selected patients in consultation with their pain management specialist or personal physician, but care must be exercised not to initiate or exacerbate psychological or tolerance-related complications of chronic pain.

From Hippocrates to HIPAA: privacy and confidentiality in emergency medicine--Part II: Challenges in the emergency department

Part I of this article reviewed the concepts of privacy and confidentiality and described the moral and legal foundations and limits of these values in health care. Part II highlights specific privacy and confidentiality issues encountered in the emergency department (ED). Discussed first are physical privacy issues in the ED, including problems of ED design and crowding, issues of patient and staff safety, the presence of visitors, law enforcement officers, students, and other observers, and filming activities. The article then examines confidentiality issues in the ED, including protecting medical records, the duty to warn, reportable conditions, telephone inquiries, media requests, communication among health care professionals, habitual patient files, the use of patient images, electronic communication, and information about minor patients.

Chronic pain and aberrant drug-related behavior in the emergency department

Pain is the single most common reason patients seek care in the emergency department. Given the prevalence of pain as a presenting complaint, one might expect emergency physicians to assign its treatment a high priority; however, pain is often seemingly invisible to the emergency physician. Multiple research studies have documented that the undertreatment of pain, or oligoanalgesia, is a frequent occurrence. Pain that is not acknowledged and managed appropriately causes dissatisfaction with medical care, hostility toward the physician, unscheduled returns to the emergency department, delayed return to full function, and potentially, an increased risk of litigation. Failure to recognize and treat pain may result in anxiety, depression, sleep disturbances, increased oxygen demands with the potential for end organ ischemia, and decreased movement with an increased risk of venous thrombosis.