WASHINGTON – Learning to differentiate between drug-seeking behavior and unmet pain needs can help emergency physicians cope better with chronic pain patients, who are frequent emergency department visitors, said Dr. James Ducharme at the annual meeting of the American College of Emergency Physicians.
It can be hard to determine when a patient is requesting medications for true pain as opposed to seeking them for diversion, he said.
However, if anything, patients are not given enough pain medication by emergency physicians–and, often, if they ask for a pharmaceutical by name, they are identified, usually incorrectly, as addicts, said Dr. Ducharme, who is professor of emergency medicine at Dalhousie University in Halifax, N.S., Canada, and clinical director of the emergency medicine department at Saint John Regional Hospital, N.B.
According to Dr. Ducharme, about 70% of people presenting to the emergency department have a pain complaint, but only about one-half of 1% are addicted.
When pain goes untreated, however, chronic pain patients, such as those with sickle cell disease, have behavioral traits that, taken alone, resemble those of addicts, he said. They see the ED as the place of last resort when they have not been helped elsewhere. Physicians often give these patients a short-acting opioid and then discharge them.
This is a mistake, though, because many chronic pain patients are already taking long-acting opioids. By giving them the shorter-acting formulations, the physicians may be creating tolerance.
Opioids also do not provide any long-term benefit to fibromyalgia patients or to those with neuralgic pain; myofascial pain syndrome; or chronic, stable, nonmalignant pain such as back pain. It is incumbent on the physician to explain this to patients, Dr. Ducharme said.
Migraineurs and others with recurrent conditions tend to know what works for them and will ask for the medication by name, but ED physicians may mistake that behavior for drug seeking, he said.
“It's not their fault if they know what they're talking about,” Dr. Ducharme pointed out, adding that migraineurs also tend to visit an emergency department only once or twice a year.
However, migraine headaches, dental pain, back pain, and recurrent abdominal pain are common scenarios cited by drug takers to procure opioids, he said. Not surprisingly, many physicians doubt these patients' veracity.
But there are ways of treating pain without rewarding addicts, he noted.
If abuse is suspected, the suspicions should be voiced to the patient. If the issue is not resolved, give the patient an oral analgesic such as morphine, but only enough to last until a physician can be seen the following day. There are other options: a dental block with bupivacaine for dental pain, for instance. The patient should not get a prescription, Dr. Ducharme said.
Physicians should not be confrontational with patients, but should suggest that they have a problem and then try to do whatever possible to treat the abuse. “If all we do is try to get them out of the ED and not address the abuse, we are ethically failing,” Dr. Ducharme said.
Unfortunately, there are no evidence-based rules for identifying drug abusers, he said, adding that being objective is also difficult. The physician's own perceptions–of who is an abuser and of what pain should look like–can shape his or her judgment about who is truly in pain and who is seeking drugs for diversion, he said.
Dr. Ducharme gave some rules of thumb. Patients who aggressively complain about needing more drugs and who hoard during periods of reduced symptoms, request specific drugs, or openly acquire similar drugs from other medical sources may not be recreational drug takers or addicts, he said.
Patients who sell prescription drugs, steal them from others, and get them from nonmedical sources are much more likely to be drug takers, he said.
Another difficulty is treating addicts in pain, as they will need large doses of a medication. Physicians should accept that reality and consider alternatives to opioids, such as epidural or regional anesthesia, ketamine infusion, and NSAIDs, Dr. Ducharme said.
Most so-called drug takers, however, are patients whose pain is poorly controlled. ED physicians can help end the cycle by having good references for patients when they go back out into the community. And, he reiterated, drug abusers should get an objective assessment and good medical treatment, despite their history.
Dr. Ducharme disclosed that he has received a speaker honorarium in the past from Purdue Pharma, the manufacturer of painkillers such as MS Contin and OxyContin.