The insanity of pain management in the ER

One of medicine’s ethical traditions is to relieve suffering whenever possible. I believe in this, and try to treat all of my patients as I myself would want to be treated under similar circumstances.

My dilemma is, even after practicing medicine for over 30 years, the definition of a “suffering patient” has become a moving target.

On the one hand, I hear arguments primarily from governmental agencies that presume to “advocate for patients in pain”, who say that we must take everyone at their word. If a person says his/her pain is a “10 out of 10”, then it is my ethical duty to employ immediately all medical interventions available to me to alleviate that suffering.

Unfortunately, our triage nurses almost never see a patient whose pain level is less than 10, and many are well over 10. Examples of “10 out of 10” pain in our ED in West Philadelphia include hangnails, paper cuts on fingers, and menstrual cramps.

We are also being told, by separate governmental agencies, that we are providing patients with far too many narcotic analgesics for their own good, and that we must do everything we can not to give potent pain medication to patients who do not obviously need them. It is often impossible to tell if a patient is really in pain, or is attempting to obtain narcotics fraudulently.

Let me tell you about a recent case in our ED. An adult female with chronic low back pain who claimed to be on daily Dilaudid oral tablets for pain management, presented to our community hospital when she ran out of her medication before her next pain management appointment. There was no acute injury, or any change in the nature of her chronic pain. Specifically, there were no new symptoms to suggest neurological impairment or infection. Of course, her pain level was a “10”, and she was placed in a holding bed in the hallway until she could be seen, due to the fact that the ED was extremely busy and there were no active treatment beds available. After waiting about an hour, our patient started complaining loudly that no one was paying attention to her. Even though we do not usually treat chronic pain in the ED, this patient was given a dose of IM Dilaudid and a prescription for a few tablets to last until she could contact her usual prescriber.

This patient registered a complaint with some agency of the state that sent an investigator to our hospital. The investigator was astonished that this patient was forced to wait until getting her medication, and gave our hospital a formal citation. We now have to comply with an action plan, with a goal of instituting meaningful symptom control for any patient with a pain level “7” and over, within an hour of the patient’s arrival to the ED. All of the nurses have to complete a course in “ED pain management”. Also, the triage nurse must inform the attending physician when a patient with a pain level over 6 is being placed in a room.

This is all insanity. True insanity. Our ED staff is intelligent, dedicated, and experienced. Regulation of this sort does nothing but nurture cynicism of the part of the staff. The nurses will follow the letter of the regulation, and the physicians will not be surprised if there are 20 people in the waiting area all with pain levels over 10, none of whom will die if not treated immediately. Nothing will have changed except we all will have been convinced of the unmitigated stupidity of our governmental agencies, and the tragic acquiescence of our hospital administrators.

Patients have learned that ED’s are basically the “corner market” for free narcotics, and there does not seem to be any legitimate will on the part of anybody to undo this, except the DEA that threatens us all with loss of licensure if we continue to do what we are told by other governmental agencies.

When will the insanity stop? Am I supposed to use my skill and judgment in prescribing narcotics, or do I respond robotically to the patient’s subjective statement? Legislative and bureaucratic micromanagement of medical practice is making it nearly impossible to treat patients in a rational manner.

I predict the Affordable Care Act will do nothing to make the problem of narcotic abuse and addiction better, and will likely make it worse. I hope against hope to be proven wrong, but I not holding my breath.

William Jantsch is an emergency physician.

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  • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

    Another excellent example of how physicians have lost “the right” and authority to be healthcare leaders. We are now viewed as civil servants to bend to the will of our patients, even when it is not rational or medically appropriate.
    I would certainly not advocate going back to the days of paternalistic medicine of the 1950s when a doctor’s word was never questioned, but we have come to the other extreme and are paying the social price for it.
    Our profession needs to be somewhere in the middle and that can only happen if we reclaim our standing and place as the medical authority in this country.
    How much longer can US healthcare withstand being controlled by insurance, pharma, and politicians?

    • LastoftheZucchiniFlowers

      Brian – agreed; but the the bigger (and only) question must boil down to this: who do we work for? For those of us whose fathers/grandfathers were physicians – we KNEW that THEY worked for themselves! Their patients came to them and paid for professional services. In the 80s, it began to change with DRG when the physician/surgeon was the income driver of the hospital vis a vis admissions/LOS and surgeries performed. Then in the 90′s ‘managed care’ morphed the scenario away from the physician, placing decision making in the hands of non-physician ‘gatekeepers’. Today – all physicians should ask themselves: who do I work for? If you can tolerate the answer and the implications of the answer, you’ll be fine. If not – it’s time to alter your reality!

      • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

        Agreed. I have changed my practice and taken back (some) control ad cont to be a “rebel”. But what does it take to stimulate the rest of the physician community to change? Physicians have a lot of inertia.
        and, how do we regain a voice at the table? the AMA doesnt speak for any physicians I know.
        how do we recreate or start a new physician organization that can begin this change on a national scale?

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          I’ve been saying this on this blog for eons, but unless you guys start somewhere, and do something, the writing is pretty much on the wall. Someone doing what you are doing should not be considered a “rebel”.

          So instead of repeating myself, just click over to this earlier kevinmd post and read the comments….
          http://www.kevinmd.com/blog/2012/05/medicalindustrial-system-long-overdue-real-shakeup.html

          • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

            Ms Margalit
            I read your comments and blog. I appreciate your views. I agree, docs need a new organization but hard to do. We are trained as independent thinkers and often “mistrust” each other, as crazy as that sounds….

            I dont think an academic would have the will or incentives to lead such a crusade.
            Private physicians (at least PCP) are busy struggling to stay a float. Social media is a great way for something like this to start, but honestly, very few physicians (mostly the young) are involved….
            not trying to sound pessimistic or defeatist but it’s worse than hurding cats.

            I think it will take a catastrophic failure of healthcare before docs would stand up for themselves (i.e. sudden drastic cuts to Medicare) and I honestly dont think politicians are that stupid, I think they will just keep baiting physicians along and slowly strangling them.

            I could only hope for absolute failure of congress to allow real cuts to occur. sounds terrible, but I think that is the only way physicians will wake up.

    • Charles Flash

      Brian. When it comes to narcotics, I have stopped listen to the so called experts, insurance companies, drug companies, etc. The last time Iisten to them, my goose was cooked alive. On listen to this who can do you the maximum damage like the Boards, local cops, DEA etc.

  • http://twitter.com/RachAPRN Rachel Heidenreich

    The health care system is a mess. I agree that things need to change and hopefully for the better. We had a recent change in the laws in KY regarding scripts written for controlled substances and patient pain control has suffered while heroin use/deaths increased. Also some of the complaints about the law from the MDs was about the rules that the KMA imposed. No easy solution.

  • Ramon Parrish

    The Affordable Care Act will move a lot of this nonsense from the ED to the Primary Care office, which will also be burdened with the same kind of regulations. I am SO tired of the “Percocet Shuffle.”

    • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

      I doubt it. There will still be 10-20 million uninsured and greater than 50 million underinsured. They will go the ER because the primary care provider won’t take their insurance.

      Plus, a lot of primary care providers, myself including. Will not RX controlled substances on a first visit and will not RX narcotic pain control for longer than three consecutive months to any patient. I refer to pain management in my area to care for these patients.

  • http://www.facebook.com/jacqui.maurone Jacqui Ballan

    Welcome to the era where a sprained ankle gets Percocet and menstrual cramps get IV morphine. Yet the sickest patients are lucky to get anything at all. Because the sickest patients make the least amount of noise. If you yell and scream and write letters you are rewarded with IV Dilaudid just so you’ll shut up:(

  • http://www.facebook.com/jacqui.maurone Jacqui Ballan

    And since when did narcotics become the end all-be-all answer to pain? :(

    • Payne Hertz

      They aren’t. Since when is denying pain medications to patients the end-all, be-all answer to pain?

      Narcotics are commonly used because they work better and are safer (when taken as prescribed) than many of the other alternatives out there, all the media hysteria to the contrary. Unnecessary surgeries cause 12,000 deaths a year but where is the hysteria over that? Where is the hysteria over other toxic prescription drugs that cause over 100,000 deaths a year, or the 15,000 chronic pain patients who commit suicide every year?

      The obsessive focus on narcotics to the exclusion of all other dangers in medicine reeks of a political and moralistic agenda. It has little to do with science.

      • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

        Work better? Where is your research? Numerous studies show that narcotics upregulate pain receptors making small pain stimuli’s much worse. Its a spiral of pain due mostly to the medications not the problem. There are many other modalities and treatments that are more or at least as effective as narcotics, especially for chronic pain.

        • Charles Flash

          Beau. I can help you with some things I discovered about narcotics in the last 3years. Trust me, your licenses may depend on it.

  • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

    I know this is a common problem. I have seen it all to much. I do have a question however.

    Have you all considered establishing an urgent care department attached to your ER?

    EMTALA only applies to pregnant and those with “a condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs”

    These “chronic pain patients” could essentially be shunted to the urgent care center either before being admitted to the ER (through a Dr. advised triage system) or after initial evaluation by the ER doctor.

  • http://www.facebook.com/chrissy.campana Chrissy Campana

    I agree that narcotics are distributed too frequently in the ED. Patients expect pain meds in the ED, particularly the ones who dont need them. Only we can change that though. As a whole, doctors are unorganized because we focus on medicine and blow off these little issues because we dont have time (or dont want) to deal with them.

    I feel that sometimes medicine is not really medicine anymore, but a business with patients thinking the “customer is always right”. I actually had a patient say that to me a few weeks ago after I gave him Tylenol for a small bruise on his leg, because he wasnt happy with my choice of analgesia. My answer? “NOPE.”

    This pay for performance +/- Press Ganey is crap too. Maybe politicians should get paid based on how happy their citizens are. Again, Im complaining like we all do instead of doing something about it :-)

  • Dave

    “The insanity of pain management in the ER”..are you kidding me???? the insanity is not getting pain management from an ER when YOUR doctor isn’t available.
    The only thing you said that made an ounce of sense is if someone comes to the ER having already taken all prescribed medication and needs more before their next appointment, well to me that person is abusing the medication.
    If 19 years as a chronic pain patient I have never once taken even one pill that I wasn’t supposed to, have never run out of pain meds “earlier” than my next appointment.
    The medical community and the drug manufacturers have let us down. Doctors are always doubtful that one is actually suffering and the drug manufacturers are not doing anything to try to create pain meds that are none narcotic nor addictive.
    You stated that “everyone” says their pain is a 10, well here is some news for you sir, whatever pain you are in at the time does feel like the worst pain you ever had. I personally have never understood where or why all the medical community has done is come up with this absolutely useless way of gauging pain.
    Thank God that there are doctors that do care and do understand chronic pain, you sir don’t seem to have a damn clue.
    As one who has had 4 back surgeries that were deemed to have failed by the doctors that performed them leaving me with what y’all call a “failed back” which only means the doctor has no idea why you didn’t improve after surgery!!!
    Before my first surgery I asked what is the chance of a good outcome and was told “only 1 to 2% of those that have back surgery don’t improve” , thought that was fairly good. So I went ahead with the surgery only to end up spending 8 years in a pain clinic and also having 3 more surgeries. What I have learned over the past 19 years is this, the surgeons tell you only 2% will not improve well those that have to clean up afterwards the pain clinic’s and therapists all say that number is more like 75 to 80% of patients having back surgery do not improve and in fact are left worse off that before the surgery. Also having multiple back surgeries in the same area of the spine should never be done, if it didn’t come out well the first time it will not come out any better no matter how many times the open you up. The biggest problem is scar tissue which needs to be removed before the surgeon can do the next surgery only to grow back twice as bad.
    My lower back is like a brick from all the scar tissue and if I knew then what I know today I never would have had a 2nd 3rd or 4th operation.
    So sir where should one go for relief if their doctor is out of town or just not available??? if not the ER then where????
    You are just another doctor who thinks it’s all in our heads well sir I’d trade places with you in a heartbeat and then you tell me I’m not suffering!!!
    Just because the “regulators” are making your nurses be trained in PM and your ER got it’s hand slapped you decided that the ER is not the place for Pain management, well I say your nurses and ALL doctors should have Pain management training and any doctor worth a damn should know that if someone presents with a “hang nail” they do not need narcotics but that doesn’t mean the person is not hurting, yet should be treated accordingly.
    The local hospital that I use has a computer system that allows any doctor you see who is associated with that hospital to see every single thing in my medical history from all my visits to my primary care doctor up to and including all procedures that I have had done even if not done at that hospital, all patients are required to have reports from procedures done elsewhere sent to their primary care doctor so they can be scanned into the computer system so there can be no doubt who is really in need of pain management and who is not.
    Perhaps complaining about how the government has made treating people a much tougher task why doesn’t the Medical community rise up in protest and become advocates for those who truly need the help???
    You stated you have “practiced medicine” medicine for 30 years and you’re right each and every doctor is just “practicing” on each patient that comes through their doors and then use us as lab rats. A ball player “practices” to get better at his trade yet I see little improvement from doctor even after 30 years of “practicing” their trade.
    I’m so angry at what you had the nerve to write I could scream but then I’d be labeled as someone in need of a shrink because in no way can a doctor ever be wrong!!

    • janet

      Dave – as an ED physician who has worked in a small community ED for over 15 years, I understand your anger., but you also do not understand the environment we work in on a daily basis. I have never hesitated to give pain medication to a patient who presents with a legitimate complaint of pain. The difficulty is determing who is legit and who is just scamming. I have always given the patient especially the patient who presents for the first time or only occasionally for pain meds the benifit of the doubt. But I have been lied to about the pills falling in the toilet, lost at the airport, stolen by a stranger who broke into their house and only stole that one pill bottle out of the cabinet,; I have had wives obtain narcotics for their headaches who turn the drugs over to the husband who in turn sells them in the ED parking lot! I have had mothers bring their teenage daughters in to scam us for narcs for their menstrual cramps; I have had patients crush and snort the Hydrocodone off the counter while still in the ED; and ai have had patients complain to administration that they only received a script for 15 pills and they “know” their neibor received a script for 90 pills! If I over-prescribe I will have the state narcotic bureau on my back. If I under-prescribe the DOH is on my a.s. I try my best to teat my patients fairly and humanely. What I don’t need is the state or federal government interfering any more in the patient-physician relationship.

      • tiny2you

        The world is not always nice, maybe it is better to let the police do what they do best and you do what you were trained to do, not one of us can read the heart, now can we?

  • Murali

    As a retired Hematologist/Oncologist, I have dealt with pain management for patients suffering from Sickle Cell Disease, Hemophilia and Metastatic cancer. Sure there are patients with chronic pain of benign etiology abusing narcotics. But that is a reality. In my view a physician is supposed to evaluate, promptly decide on the treatment and administer through the staff. ED is a place for critically ill and to deal with trauma, but it does not say ONLY those kind of patients should visit. It is open for all patients with what they consider to be immediately addressed and the triage Nurse as well as the MD can decide on the nature of therapy to be rendered. If we have this attitude towards “Suffering” patients, when they are inundated with more “Insured” patients in the future, what would happen? Also, the cost of the per hour charge at the ED, for no fault of the patient who comes in is another issue. Give the benefit of the doubt to the patient,

    unless the staff or the MD know about this repeat offender who abuses the drugs. When the providers become patients, then they will know how the other side is.

    • tiny2you

      Thank you. Very well stated Doctor, all the good ones are retired,sadly to say.

    • ninguem

      The ER’s used to have “turkey files” or similar names of the known repeat offenders.
      They’re generally not allowed to have them anymore.
      They’re not allowed to have the information you allude to.

  • tiny2you

    Living with pain is a life long endless battle, a patient begains treatment with a pain management physican, most are not seeking heavy drugs, just some type of relief, but these physicans get these people on heavy narcotics, try being given methadone 10mg three or four times per day, then suddenly when the physican thinks you are cured of your pain , without any type of medical intervention on their part, no physical therapy, no acupuncture, nothing, but sudden decides to cut your medication down to quickly, or worse yet, God forbid your insurance is cancelled and the patient can not afford to pay the $150 per visit, you medication supply is fast, and in a hurry, cut off, have you ever felt the pain and dispear that occurs when suddenly cut off methadone or any pain medication for that matter?not only do you have to endure the dispair of the chronic pain but also the withdraw pain as your body craves what its use to having.
    The ED seems at that time, as your pain increases to be your best friend, until you arrive there and some stressed out nurse tells you there is a 3 to 5 hour wait becsuse other people have a REAL emergency. What about the doctor, not only is it the young fresh out of med school physican but also the so called experienced physican, who assumes your seeking drugs for.pleasure or even worst too sell! When they learn you were given methadone,.they assume you are a heroin abuser (someone Please Call My Pain Management Doctor!)user even though the pain management team felt methadone was the drug of choose for long acting pain control. So Now what? the ED Physican right away tries to and wants to get you out of there face, telling the nurse to give you 2mg or maybe 3mg of hydromorphone and sending.you home with a script for Norco, which if they really wanted to help the suffering patient would know that neither the 2 or 3mg would ease the suffering or the Norco.
    Who is at fault? surely you can not blame the patient, by putting trust in the pain management specialist their whole life is now affected, changed and the whole pain mangement treatment Is ALL Just.a Mask, It is Not Really Solved And They All Think.you Are A drug Seeker, and the pain doctor keeps making his dollars and getting his free samples and lunches from the drug reps.

    I feel the pain management and ED physicans should both considet what it is they are doing.and how they are having a big impact on not only the patients pain but how they are affecting a persons life,.and this, what I am sharing in this discussion is coming from not only myself as a patient, but I am also a Nurse who can actually hear my patients complaints and can actually feel their pain.
    and who are you or anyone else to say otherwise unless you can walk in their shoes.

    • margo

      I think pain is a very complex problem and one of the biggest problems is that it can often be very time intensive to diagnose. The ED is definitely not the place to solve most of these problems–unless the pain of course is truly defined as a medical emergency. I can see that State Boards get a lot of complaints from pain patients getting inadequate care. They are bean counters and solve the problem like this article shows. Or making physicians take pain CME to keep their license active. All of this as we know does not solve the problem and maybe hinders it.

      Unfortunately the medical system being broken is perpetuating these problems. Since pain is not a diagnosis and only a symptom it can take time to diagnose and often pts are shuffled from one place to another with little if any coordination of care. So where does every pt go these days to get medical care but the ED. There are often long waiting periods to get into pain clinics etc. Given the pt load and time constraints everyone has these days these pts often are the ones that get overlooked. And yes we know there are always the drug abusers and personality disorders.

      • Charles Flash

        Margo. Perfect analysis. We practitioners have been set up to fail. Read my book if you want protect yourself.

        • ninguem

          Well, I’ll bite……..what’s your book?

    • http://www.facebook.com/eva.dickinson.96 Eva Dickinson

      But when you try to implement procedures such as pain relief therapy using physical therapy modalities, cognitive behaviour techniques, and other interventions you are targeted by the insurers not wanting to pay. Just look at my case where I have had my payments suspended for over a year without any real hearing because I am trying to treat outside of the box of narcotics and for that my career, reputation, marriage and has been ruined. I have no appeal rights or anyone or place to turn to and that is what happens when a doctor tries to go above and beyond the normal standard which we all know does not work. As for the methadone look at all of the insurers that have placed it on as a preferred drug on their formulary even though at least 30 per cent of prescription deaths in pain management are due to methadone.

      • Charles Flash

        Eva. I feel your pain. Do not be forced into committing murder with methadone but the insurance companies that will throw you under the bus as soon as the charges are handed down. If you want to know how to protect yourself, shoot me an email.

  • Purple Kangaroo

    While I understand the gist of the article, I did want to mention that for some women with issues such as endometriosis, “mere menstrual cramps” can be EXTRAORDINARILY painful. We’re talking crippling, brain-numbing, vomiting, passing out, grinding teeth, almost-wishing-to-die, please-hit-me-over-the-head-so-I-can-lose-consciousness levels of pain.

    I hope that most ED staff know better than to assume that just because a woman is complaining of hormonally-associated pain, does not necessarily mean the pain is minor.

    • http://pulse.yahoo.com/_AQGAJ4XQOZ56VG4GULIC324QCQ That really cool Sarah

      Thanks for that. The haughty dismissal of menstrual pain, hurt my feelings. I was fine and thought the same thing most of my life. Then came middle age and the most debilitating pain I’ve ever experienced with cramping and pain far worse than the pain I had during childbirth (not to mention, major surgeries and broken bones, swan-song dental pain, and a neuroma that delivered hideous electrical shocks). The emotional distress that comes with serious pain is hard to describe. I’ve had pain that massive doses of NSAIDS could not control, and spent hours trying to be very very still in bed, moaning and absolutely unable to walk upright to the restroom. When it finally ceases you understand how it tears you down in body and soul and wonder that anyone would have to live like that ALL THE TIME. I would kill myself.

  • http://warmsocks.wordpress.com/ WarmSocks

    Ah, it sounds like you’ve been scammed by people like my SIL. She suffers horribly from kidney stones. I think she likes to suffer. She will not follow her doctor’s advice, and will not take the medicine that was prescribed to prevent new stones, nor will she make any dietary changes. In fact, she does not believe that she should have to do anything because “it is the doctor’s job to cure her.”

    Whenever the pain strikes, she goes to the ER for more pain pills. Sometimes she’ll even stop at urgent care for a prescription before heading to the ER for IV pain relief and another prescription — those two scripts get filled at separae phamracies to avoid red flags. In October, she was in the ER 15 times, plus urgent care a couple times, and was offended when doctors suggested that she might have a drug problem. She honestly believes that her problem is from kidney stone pain, not from drug addiction.

    Nobody is doing her any favors by enabling continued drug abuse. People who keep returning for more and more pain meds need to be referred to inpatient drug rehab, then to pain management, not given IV dilaudid then handed yet another vicodin prescription.

    • tiny2you

      WarmSocks, you sound like yoi know what your patient needs, the only problem I have is what happens if the patient has increased pain and took maybe three tablets of Methadone instead of two and runs out of meds too soon and has no choice but to go to the ED because you wont touch the issue and its your way or no way and the Vicodin does not help becsuse the Methadone blocks the pain receptors, should not that patient be treated in the ED? and by the way, vicodin does not help the pain when your on methadone, is if a person has true chronic pain, and a

      • http://warmsocks.wordpress.com/ WarmSocks

        You ask if the person should be treated in the ED. No. Absolutely not. The Emergency Department is for emergencies, i.e. heart attacks, vomiting blood, those injured in car wrecks, violent crime victims…
        Chronic problems are not emergencies. If a person runs out of prescription medicine, that is not called an emergency; it is called poor planning.

        My comment was not about my patient. It’s a family member who is ruining her life with prescription pain pills obtained in the hospital ER. She has a job, but works 3 hours, then goes home sick when her pain pill wears off. Everyone rolls their eyes, because she’s in too much pain to sit at a computer at work, but has no problem sitting at a home computer. She’s in too much pain to work Monday through Thursday, but feels just fine to go out on Friday nights and spend time with her friends all weekend.
        I had a lot more sympathy for those in chronic pain until I met a few. The pain could be eliminated or greatly reduced by other methods. Narcotics do not help the problem. Narcotics make the problem worse. It might be nice to have a magic pill that made everything better, but life doesn’t work that way.

  • http://www.facebook.com/jeffrey.balfus Jeffrey Balfus

    As pain management specialist, now retired, I would say that “acute pain scales” have no place in treating chronic pain. Also, rapid acting narcotics should not be used for long term pain. They have high abuse rates and produce tolerance way to quickly.

    The patient with drug abuse and chronic is very difficult to treat. I used Methadone for daily base and Vicodin for break thru pain. Also a strict understanding – no meds from other docs, no ER visits and no early refills (unless they could come up with something really original!).

    • Charles Flash

      Jeffrey. You are lucky to have escaped. I envy you.

  • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

    the real problem is that we have poor treatment options for chronic pain. The science is increasingly telling us that long term narcotic use only up regulates pain receptors and makes patients MORE sensitive to pain. So are we really helping with narcotics for chronic pain? we are probably only dooming patients to even more pain and higher demand of narcotics.

    but, when presented with a patient with complaints of chronic pain, we dont really have any other good options At least none that most patients find acceptable.

    Until that research is done and better options are discovered, I suggest we need to educate our patients a whole lot more. They need to know what a slippery slop narcotics are and how they must strongly consider the long term implications of narcotic use before succumbing to this line of treatment. There will always be abusers, but for the majority of chronic painers, I think they have been poorly informed and have been lead down a garden path of narcotics from which the return is difficult, if not impossible.

    Before this walk down the narcotic road is taken. Must seriously look at their life and decide, just how bad is this pain and is it possible to live with or manage in another way?

  • margo

    I think pain is a very complex problem and one of the biggest problems is that it can often be very time intensive to diagnose. The ED is definitely not the place to solve most of these problems–unless the pain of course is truly defined as a medical emergency. I can see that State Boards get a lot of complaints from pain patients getting inadequate care. They are bean counters and solve the problem like this article shows. Or making physicians take pain CME to keep their license active. All of this as we know does not solve the problem and maybe hinders it.

    Unfortunately the medical system being broken is perpetuating these problems. Since pain is not a diagnosis and only a symptom it can take time to diagnose and often pts are shuffled from one place to another with little if any coordination of care. So where does every pt go these days to get medical care but the ED. There are often long waiting periods to get into pain clinics etc. Given the pt load and time constraints everyone has these days these pts often are the ones that get overlooked. And yes we know there are always the drug abusers and personality disorders.

  • WhiteCoatRants

    Please provide us with the name of the agency and the name of the investigator.

    Ridiculous actions like this need to be publicized.

  • f. lusu

    a patient with low quality of life is sent over to pain management because his primary is literally afraid to rx narcotics to anyone, his dr is going to retire in a couple years and doesn’t want to have any state agency ever investigating him.(knock on wood). the dr. feels those meds will be helpful along with other treatments. the patient goes to pain management,has his picture taken like a criminal, and signs paperwork that tells him to go to the ED on weeknights or weekends. a few pharmacy employees look at him with distaste as he sits there for 20 minutes waiting for his prescription.
    even getting his ‘monthly’ 28 day script is an issue. if he holds on to the script for a few days,he finds out that he must wait exactly 28 days before refiling it again,which isn’t a problem unless there is break through pain. then he might be in the ED again. in a world of depression and pain, he feels abandoned by his primary,manipulated by pain management, humiliated in the ED, and now goes to a drive through pharmacy so he doesn’t have to face the looks he might get there. there is little dignity left for this patient

  • Payne Hertz

    Reading this article, one would have to conclude that people in severe pain rarely go to to the ER, otherwise why the surprise at seeing people reporting high pain levels? Instead, people with paper cuts are the ones who go to the ER, and report their pain as being level 10.

    Somehow, I think the reality is precisely the reverse.

    These good doctor/bad patient articles complaining about patients allegedly “exaggerating” their pain always seem to be highly exaggerated themselves.

    If a patient “exaggerates” their pain so what? Does reporting level 8 pain as level 10 really make that much of a difference? You seem to think patient reports of pain should have the precision of the Richter scale, rather than being very subjective approximations. A patient can honestly rate the exact same pain stimulus at different levels at different times depending on their mood, level of fatigue and other mitigating factors. In my opinion, doctors who get hung up on the pain scale are really just looking for another way to demonize their patients and deny them treatment.

    Let’s also remember patients aren’t the ones who invented this bone-headed system or the idiotic 1 to 10 scale. Doctors did. We are just the ones who have to suffer through its crass stupidity and cruelty.

    I find it highly doubtful a bunch of nurses and doctors got sent to the reeducation camp because a patient had to wait a grand total of one hour to get her pain treated and complained about it. I mean, srsly.

    I think it had more to do with this:
    “Even though we do not usually treat chronic pain in the ED”
    than this:
    “One of medicine’s ethical traditions is to relieve suffering whenever possible. I believe in this, and try to treat all of my patients as I myself would want to be treated under similar circumstances.”

    I highly doubt you would want to be denied pain treatment when your pain level is a 10.

    Consistently denying people pain treatment for no other reason than the type of pain they have, falsely accusing them of exaggerating their symptoms and being drug-seekers…yeah, I can see that leading to a few complaints, and rightfully so.

    The only insanity here is that adults are not allowed to treat their own pain but have to be subjected to a system that is designed solely to milk them like cows in their hour of despair.

    The solution is to end drug prohibition and allow patients to become licensed to use these meds on their own after completing a training course. Then there won’t be any more desperate midnight runs to the ER for toothaches.

    • Faxon

      I can’t agree with you more. The only time I was in an emergency room was for a true medical emergency; my PCP sent me. I was doubled over in pain. Someone asked me what my pain level was on a scale of 1 to 10. I had no idea what they were talking about, or how to answer such a moronic question. The “war on drugs” is a war on the citizen and a money maker for criminals. I do also have sympathy for the medical community who must practice medicine under the shadow of the War.

  • Payne Hertz

    C’mon Ninguem, you don’t recognize that article was a hatchet job? Dr Portenoy was obviously quoted out of context, as you can see from the video where some of that context was included.

    “The article quoted me accurately but selected a few quotes from a very long interview.

    It lacks the voices of people with chronic pain, greatly overstates for dramatic effect both my influence on medical practice and the changes in my thinking, ignores the hyperbole and overreaching of those who seek to reduce overall use of these drugs without worrying about access for those who could benefit, and is in my opinion more about the reporter’s viewpoint than mine. I do not endorse its take-home message.”

    http://paindr.com/prompt-position-remains-unchanged/

  • Rob Burnside

    Some time ago, while working 2nd shift at a psychiatric hospital, I heard a colleague remark, “You should have been here ten years ago. Getting the patients settled down was much easier back then–everybody got a complimentary Thorazine cocktail at bedtime!”

    I’m on the tail end of this one, and it may be where my comment belongs, but what’s wrong with a preemptive whiff of nitrous oxide, on triage, for the usual Emergency Department suspects? It’s inexpensive, safe, non-narcotic, easy to administer, rapidly efficacious, short-acting, FDA approved, and bound to make the ED a more pleasant experience for all concerned.

  • Michael D. Catania, PharmD

    I have been a pharmacist for 15 years and could not agree more. These people who seek out narcotics delay the care for those who really need medical attention.

  • Charles Flash

    With regards to narcotic prescriptions, we’ve lost our rights to the so “called leaders” because we have not taken the steps to understand our responsibilities and limitations under the law. Until we empower ourselves, expect sham treatment from investigators, prosecutors and healthcare leaders who do not know jack. If you want to protect yourself contact me.

  • http://www.facebook.com/eva.dickinson.96 Eva Dickinson

    I don’t need protection; I need a miracle. But I am willing to listen to any advice you are willing to give.

  • http://www.facebook.com/cindy.langr Cindy Langr

    Cindy Langr clangr1@aol.com
    I am a person with chronic pain. If insurance companies would cover the services I need for pain (surgery) I would not need to go to the ED for help. I have only been to the ED once and suffer daily because of my insurance company. When is someone going to do something about those people who get make decisions about my life without knowing anything about me other than what the dollar sign says. I do not go to the ED unless I absolutely have to, which is very infrequent. I live with a pain level of 8 on a daily basis with pain meds. What are those of us who are in true pain due to disease or other supposed to do?

  • querywoman

    Narcotics are not the only way to manage pain!
    Golly gee! There was a time when I repeatedly told doctors in their offices that I had painful neck spams. They often dismissed it as “stress.” I have spent a small fortune on stuff like muscle relaxants, etc. Narcotics were never that helpful.
    And then sometimes I ended up in emergency rooms with it!
    I was often told to use “moist heat.” I tried a chiropractor only 2 times, but she told me to use ice, not heat, and it worked!
    Nonsteroidal anti-inflammatory medicines also helped, but several did not work, so I had to keep going.
    Eventually, yoga also helped. I have not had a muscle relaxant in over 20 years!
    But nobody ever investigated the cause! Just “stress” – hah! Yes, I found it myself, overwork on a work computer in cramped conditions!
    And the cause of the muscle tension would have been obvious if I had been asked what I did for a living! Repetitive stroke injury has been common in this country for about 25 years!

  • Ariana Tobe

    I can’t speak from experience, but my father has been an emergency physician all of my life, and I hear from him all the time about how stressful it is in the ED. He always talks about how patients come to the ER seeking unnecessary treatment, which just sets back the entire ED. I understand that some patients may believe that they are not being treated fairly, but they also need to know that there are most likely other patients that need care first, depending on the severity of their injuries.