Scenario 1: Mr. Smith is a 42-year-old male who has come to the ED because he is in severe pain from a chronic low back condition lasting at least 10 years. He cannot stand upright. He moved into town when his company closed two months ago so he could stay with his sister. He is unemployed. He says his meds—duloxetine, tramadol, and celecoxib—are running out. There is no pain clinic in the community, and he has no family physician.
Scenario 2: Mrs. Smith is a 51-year-old female with 15 years of chronic neuropathic leg pain. She has been discharged by her family physician because her urine tested positive for cocaine twice—she admits this because she is desperate to get care. The physician rapidly tapered her off opioids (in 10 days), and she has just finished a horrible week of withdrawal. She comes into the ED with severe pain and has no analgesic prescriptions.
These types of scenarios are not rare in emergency medicine. After all, we are the safety net for health care. Patients with varying types of chronic medical conditions and nowhere else to go end up in the emergency department and are routinely seen in county hospitals. Emergency physicians have had no training in any chronic medical condition, including chronic pain with its inherent biases and risks of opioid misuse. Just as we do not provide ongoing care for patients with insulin-dependent diabetes, we should not provide ongoing care for patients with chronic pain. There is a difference, however: patients with the former can continue to receive insulin and can often be cared for in hospital or community clinics, whereas the latter are shunned. Further, emergency physicians have received zero training in chronic pain and so often have a starting viewpoint that this is “not our problem.”
We are all responsible for every script we write. No physician in the ED should initiate opioids for patients with chronic pain, renew prescriptions of opioids for such
patients, or provide short-acting opioids to “get them out of the ED.
When you talk to patients with chronic pain who have been successfully managed, they will usually state how they have learned to deal with their problem and how their coping skills have improved. They will tell you that medications ultimately played a minor role—essential for getting the pain under control at the start but less important as other steps are taken. The American Pain Society will tell you that mindfulness is an essential primary aspect of care for these patients. Patients with fibromyalgia will experience a 75 percent decrease in pain if they complete and maintain a four-day-a-week exercise program for at least four to six weeks. How does this help us in the ED? We need to sit down with these patients and help them review how they are in charge of their illness; dependency on others is a sign of failure. Specifically, areas patients need to work on include: