Patient experience of care surrounding opioid analgesics for chronic pain is a challenge we face in emergency medicine. While it’s important to treat pain in all of our patients, best practices recommend against the use of opioids for chronic pain.⁷ Additionally, chronic pain is best managed by a primary care provider, not an emergency physician. Complaints of poor patient experience for this reason should be reviewed, but if some kind of analgesia was provided or recommended, Dr. B has likely adequately addressed the pain complaint. From a quality assurance prospective, patient complaints such as this may offer a useful path to discuss what may be far more substantive and helpful to Dr. B.

Case 5: Physician, to Heal Thyself, First Do No Harm

Dr. C has a high rate of opioid prescriptions and orders in the emergency department. A nurse informs the department chair that she believes he has pocketed some ordered opioids. Who should monitor possible substance abuse and diversion?

Suspected substance abuse and diversion should be directly addressed with Dr. C by his supervisor (eg, department chair) and, perhaps, employee health. If there is concern about substance use before shift or on shift, he should be pulled off the clinical schedule and undergo a fit-for-duty evaluation. In many states, if a physician self-reports abuse to the medical board, the disciplinary action of the board is often more favorable than if the physician is reported by someone else. There are several national groups that facilitate physician rehabilitation and return to the workplace. Normally, an employer may not take action against the employee because the employee has exercised the right to partake in the Family and Medical Leave Act.

(FMLA) for treatment for substance abuse.⁸ However, if the employer has an established policy applied in a nondiscriminatory manner that has been communicated to all employees and that states under certain circumstances an employee may be terminated for substance abuse, pursuant to that policy the employee may be terminated whether or not the employee is presently using leave under the FMLA.

Dr. Marco is professor of emergency medicine at Wright State University Boonshoft School of Medicine in Dayton, Ohio.

Dr. Lall is assistant professor and assistant residency director in the department of emergency medicine at Emory University School of Medicine in Atlanta.

Dr. Wong is an instructior of emergency medicine at Beth Israel Deaconess Medical Center and Harvard Medical School in Boston.