This action might not be possible to undo. Are you sure you want to continue?
January 20, 2007
Char Count= 0
Advanced Emergency Nursing Journal Vol. 29, No. 1, pp. 35–40 Copyright c 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins
O F N O T E
Column Editor: Karen Hayes
A Challenging Case of Chronic Pain in the Emergency Department
Medical and Ethical Issues of Management
Courtney Reinisch, MSN, RN, APN-C Abstract Pain is a common problem seen in all areas of healthcare including the emergency department (ED). Chronic pain is a condition that requires specialized management. EDs provide episodic care and are often faced with the challenge of managing patients with chronic pain. Some of these patients present with drug-seeking behaviors that make it difﬁcult to provide appropriate care for their condition. This article presents a case of a patient with chronic migraine headache, and the ethical issues surrounding her management in an ED, with focus on the patient’s autonomy, and the concepts of nonmalﬁcence, beneﬁcence, and informed consent. This article concludes with recommendations for ED to appropriately and safely manage patients with chronic pain. Key words: autonomy, beneﬁcence, chronic pain, drug-seeking behavior, ethical issues in emergency care, informed consent, nonmalﬁcence
rs H was a 45-year-old woman being treated for migraine headaches by a psychiatric neurologist after other organic problems had been ruled out. Her oral medication regimen included gabapentin, topirimate, and propranolol for headache prophylaxis and oxycodone for breakthrough headaches. When necessary, her physician administered intramuscular injections of meperidine and hydroxyzine for
From the Robert Wood Johnson University Hospital, Hamilton, NJ; and the School of Nursing, Columbia University, New York, NY. Corresponding author: Courtney Reinisch, MSN, RN, APN-C, School of Nursing, Columbia University, New York, NY 10032 (e-mail: email@example.com).
breakthrough pain. The patient and her physician had a contract stating she would only take the narcotic medications that he prescribed and she would not go to the emergency department (ED) for pain medications. Mrs H had been employed as a licensed practical nurse, however, because of her condition, her license had been suspended. Mrs H did not maintain her contract. She visited multiple EDs, requesting pain medications including meperidine and hydromorphone. If the first ED provider refused treatment with narcotics, she would go to the next local ED and demand the same medications. According to Mrs H’s spouse, she also obtained narcotics illegally.
The ED staff felt this course of action was dishonest. The Joint Commission on Accreditation of Healthcare Organizations states that pain is undertreated and mandates pain be assessed as the fifth vital sign. The issues of pain management in the presence of addiction needed to be discussed in relation to the ethical principles of autonomy. All providers in the ED signed the letter. The letter was carefully worded to ensure that the patient understood she was welcomed in the department. unethical. beneficence. as a group. race. Current guidelines on appropriate treatment of pain in the ED further impacted this patient care dilemma. Some providers would treat Mrs H with whatever medication she requested. This decision was based on the premise that emergency care is episodic in nature and treatment of her condition required specialized management from a headache or pain specialist. When advised that she could not select her provider in the ED. but that narcotics would no longer be administered for this particular condition. and she attended an inpatient program. Her speech was slurred. Given her presentation. and informed consent. Upon discharge. managing the patient’s condition in the ED remained a challenge. Given the treating physician’s recommendation to use a placebo. . and had tremors. She walked with a shuffling gait. The advanced practice nurses. risk management and the ED staff reached an agreement. As a result of the meetings. The patient’s behavior and frequent visits were a source of contention for ED providers. the patient and her treating physician agreed that she needed rehabilitation for her narcotic addiction. leaving her to be seen by another provider.LWW/AENJ LWWJ302-08 January 20. According to the commission. visiting local EDs demanding narcotic pain medications. and would cause more harm than good. She threatened to harm members of the ED staff if they would not treat her with narcotic pain medications. some providers refused to evaluate this patient. The patient’s behavior compelled our ED personnel to examine the ethical issues surrounding this case. The patient’s aggressive behavior escalated. The hospital’s risk management team and the patient’s neurologist were consulted to determine what could ethically and legally be done for this patient since EDs are required to stabilize every patient that enters the department regardless of sex. A certified letter was sent to the patient advising her that ED personnel would no longer treat her migraines with narcotic medications. 2007 22:12 Char Count= 0 36 Advanced Emergency Nursing Journal After several years. The patient did not want to be treated by the advanced prac- tice nurses because she felt they were less likely to treat her with narcotics. a provider must believe a patient to be experiencing the level of pain he or she reports and to treat the pain appropriately. and illegal. which was the practice in his office. while others refused to treat her with narcotics due to her addiction and worsening condition and violation of contract with her neurologist. The patient’s clinical status continued to deteriorate. and ability to pay. she would leave before being seen. she relapsed and resumed her previous behavior. felt that treatment with narcotics was not in her best interest. She would be evaluated and treated with the nonnarcotic headache medications recommended by her neurologist. The staff within our ED recognized the serious nature of her condition and developed a plan to contact her treating physician at each visit. These providers complied with her demands to facilitate her discharge without incident from the ED. Her physician recommended that we inject the patient with saline and tell her we were giving her meperidine. and subsequently file a complaint stating she was not being treated fairly because her request to be seen by a particular physician was not honored. She displayed manipulative behavior by requesting to be seen by providers she believed would treat her with her drug of choice. The following actions were taken. nonmalficence. medical condition.
anxiety. Pain intensity may be a driving force behind undesirable patient behaviors (Trafton et al. Patients in pain have increased rates of depression. 2004). Chronic. lasting from time of injury to 2 weeks. subacute from 2 weeks to 3 months. toothache. Horst. Appearance change or use of alias Note. Adapted from Vukmir (2004). providers must believe patient complaints are legitimate. Patients with drug-seeking behaviors may present with a variety of complaints or requests. Johnson. To avoid pseudoaddiction. This causes increased drug-seeking behaviors and cravings in patients with substance use disorders (Trafton. Minkel. report a high tolerance to drugs. mood disorders. This behavior will increase if pain is not adequately controlled. 2004). Chronic pain is defined as persistent or episodic pain of a duration or intensity that adversely affects functioning and well-being of the patient attributable to any nonmalignant etiology (Vukmir. 2002). Common complaints include headache. .. and hallucinations. & Humphreys. No. Multiple visits 2. 2004). Appropriate pain management may help patients with substance use disorder to control their illicit substance use (Trafton et al.. 2007 22:12 Char Count= 0 January–March 2007 r Vol. Depression rates increase with increasing rates of pain (Trafton et al. Problem categories include patients with chronic pain who need specialized follow-up and do not benefit from additional analgesics given in the ED. Initially. nonmalignant pain accounts for 10% to 16% of outpatient visits and 25% to 40% of hospitalizations (Weaver & Schnoll. “after hours. 2002). hospitalizations. healthcare utilization. Pain drives drug seeking for opioids in both animals and humans. Problematic behaviors such as health complaints. A desires for narcotics 7. and chronic. Overly creative requests 11. Lost prescriptions 4. A primary provider that is not available 5.” or reporting that they are from out of town (Longo. Depression. 2004). may “lose” a narcotic prescription. illicit drug use. providers can distinguish between addic- Table 1.” Doctor shopping is another common drugseeking behavior where the patient sees multiple providers to obtain an adequate or increasing supply of prescription narcotics. suicidal ideation. Patients’ demanding behavior to obtain medications can cause them to claim an allergy to nonaddictive medications. lasting beyond 3 months (Vukmir. 1 Chronic Pain in the Emergency Department 37 DISCUSSION OF CONTEXT AND ETHICAL PRINCIPLES Drug-Seeking Behavior for Pain Management Pain is the most common presenting complaint to a physician’s practice (Weaver & Schnoll. Drug-seeking behaviors 1. 2004). Assessment and treatment of pain in the ED is unique and presents challenges. tion and pseudoaddiction (Weaver & Schnoll. Parran. 2004). it is nearly impossible to distinguish between an addict who seeks increasing levels of pain medications for euphoria compared with a patient in pain who has undertreated pain. as identified in Table 1 (Vukmir. decreased physical function. Pain is often associated with mental health problems and functional and social disability.LWW/AENJ LWWJ302-08 January 20.. Drugseeking behavior for pain relief is defined as pseudoaddiction. ureteral colic. Oliva. Pain can be classified as acute. and abdominal pain 9. Once pain is appropriately managed. It may be difficult to assess and identify those who seek and abuse drugs within the ED setting (Vukmir. Allergy to alternative medications 6. The inability to focus on anything other than the medication 3. and suicidal ideation improve with adequate pain control. Drug-seeking behavior occurs with both active addiction and pseudoaddiction. 29. or claim to “run out early. 2004). These patients are often seen in EDs. 2002). Substitutes benzodiazepines 8. 2000). and suicidal ideation all increase with pain. Pain is described as “unbearable” 10. & Kinsey.
Shalmi (cited in Warfield & Bajwa. or other conditions that restrict their options (Beauchamp & Childress. 2007 22:12 Char Count= 0 38 Advanced Emergency Nursing Journal 2004).LWW/AENJ LWWJ302-08 January 20. 2001). and autonomous choice is a right of patients (Beauchamp & Childress. she ceased to be able to make decisions that were in her best interest due to her worsening condition. She was impaired because of her drug-seeking behavior. Pain management is difficult because it relies on subjective data with little objective support. Spectrum of aberrant drug-related behaviors that raise concern about the potential for addiction Less suggestive of addiction Aggressive complaining about the need for more drug Drug hoarding during periods of reduced symptoms Requesting specific drugs Openly acquiring similar drugs from other medical sources Occasional unsanctioned dose escalation or other noncompliance Unapproved use of the drug to treat another symptom Reporting psychic effects not intended by the clinician Resistance to a change in therapy associated with “tolerable” adverse effects with expressions of anxiety related to the return of severe symptoms More suggestive of addiction Selling prescription drugs Prescription forgery Stealing or “borrowing” drugs from others Injecting oral formulations Obtaining prescription drugs from nonmedical sources Concurrent abuse of alcohol or illicit drugs Repeated dose escalation or similar noncompliance despite multiple warnings Repeated visits to other clinicians or emergency departments without informing the prescriber Drug-related deterioration in function at work. and patient dose escalation are signs of pseudoaddiction. 2004). 2004). Table 2 illustrates behaviors more or less consistent with addiction. It is reasonable to question whether treating this patient in the ED also contributed to her drug-seeking behavior and addiction. and disabled as a result. Autonomy Personal autonomy is defined as self-rule that is free from both controlling interference by others and from limitations such as inadequate understanding that prevents meaningful choice (Beauchamp & Childress. anxiety. coercion. She was unable to be an active participant in her care due to her de- Table 2.” by C. as well as higher rates of depression. Autonomous persons with self-governing capacities sometimes fail to govern themselves in particular choices because of temporary constraints caused by illness or depression or because of ignorance. L. There is a greater success in managing pain with a long-term patient relationship as opposed to the brevity of an ED visit (Vukmir. The hallmark of pseudoaddiction is that aberrant behaviors disappear when adequate analgesics are given to control pain (Todd. From “Opioids for Nonmalignant Pain: Issues and Controversy. 2001). Patient reports of distress associated with unrelieved symptoms. and altered mental status (Vukmir. aggressive complaining about the need for higher doses. Respect for autonomy is a professional obligation in healthcare. particularly for populations served by the ED. 2004). Given the high prevalence of chronic pain and the limited availability of pain management resources. pseudoaddiction is the most likely cause for a large proportion of drug-related behaviors deemed aberrant. in the family. sire to reach her goal of obtaining her drug of choice. or socially Repeated resistance to changes in therapy despite evidence of drug effects Note. 2001). Dissatisfaction with pain management is more likely with more severe pain. Although Mrs H continued to be autonomous. Some providers who would treat her with . 2005).
In addition. This was an unfortunate outcome of attempting to benefit the patient by offering pain relief. what was once a beneficial treatment became a detriment. Informed Consent When initiating the prescription for narcotic pain medications. Providers would have not prescribed narcotics if they thought this patient would become addicted. An informed consent is an individual’s autonomous authorization of a medical intervention (Beauchamp & Childress. However. In Mrs H’s case. some ED providers receive limited training in recognition and appropriate interventions for such problems (Todd. Emergency care is episodic by design. Nonmalﬁcence and Beneﬁcence The concept of nonmalficence can be defined as the obligation to intentionally do no harm. 2005). The question in this patient’s management was whether the healthcare providers caused her harm by treating her with narcotics. On the basis of research in this topic. with multiple providers providing care. Over time. Therefore. She would receive temporary pain relief and avoid withdrawal symptoms. Our profession should abandon the term drug-seeking behavior. the ED is an appropriate site for screening and intervention for both alcohol and drug problems. 1 Chronic Pain in the Emergency Department 39 increasing doses of narcotics reinforced the patient’s behaviors. as well as the possibility of mild-to-moderate rebounding when the medication is discontinued (Longo et al. because there is a lack of research in this area by emergency medicine investigators (Todd.LWW/AENJ LWWJ302-08 January 20. patients need to be informed of the potential for physical dependency. and consult. Generally. She was driven to obtain narcotics that did not allow her to consider risks and benefits of treatment. 2005). the outcome was not intentional. 2004) (Table 3).. Emergency Department Management Given the volume of patients with substance abuse disorders. thus worsening her drug-seeking behaviors. healthcare providers are caring individuals attempting to keep their patients from receiving harmful treatments while providing beneficial care to their patients. However. 2005). Participation in her care was not a motivation. it was difficult to determine which treatment would deliver the greatest benefit without causing harm. 2001). whereas beneficence can be defined as the obligation to promote or do good (Beauchamp & Childress. 2001). in part. 2005). Healthcare providers lost objectiveness due to her escalating drugseeking behaviors. what should EDs do when faced with these patients? There is paucity of treatment guidelines and best practice standards for ED pain care. depending upon the particular case. Informed consent is obtained in some context for medicines for which shared decision making is not possible. the American College of Emergency Physicians (ACEP) offers a policy statement for pain management in the ED (ACEP. Close attention needs to be paid to these patients to ensure that they receive the specialized level of care they deserve (Todd. Other caregivers felt that providing narcotic pain treatment in the acute arena would be the only reasonable choice. Obviously. since for the patient in pain. These patients require close observation and treatment by pain specialists or drug addiction specialists. Some providers felt that treating her pain would be harmful for her condition. 2000). those who would not treat her and put her into withdrawal may have increased her pain. Mrs H was unable to truly give informed consent for any treatment because she was often under the influence of a variety of substances. seeking an analgesic is the height of rationality. patient referral. 2007 22:12 Char Count= 0 January–March 2007 r Vol. 29. a contributing factor to her presentday addictive behaviors. No. and educating . recommendations for future cases may include developing local policies. Aberrant drug-related behaviors as the term suggests is a broad range of behaviors that are acceptable in the context of pain therapy (Todd.
Providers have a duty to limit the personal and societal harm that can result from prescription drug abuse. (2002). including the use of pain therapy adjuncts and how to minimize pain after disposition from the ED.761–769. Trafton. 198. OH: McGraw-Hill.. Treatment needs associated with pain in substance use disorder patients: Implications for concurrent treatment. Since relieving pain and reducing suffering are primary responsibilities of EDs. K.. (2005). A. Refer patients with chronic pain syndromes to pain management specialists for outpatient management 3. Columbus. 61(8). H.. 44(2). P. T. L. & Bajwa.. Z. Principles of biomedical ethics (5th ed. & Childress. New York: Oxford University Press. 33(4). Warfield. B. 2401–2408. B. (2001).. F. (2004). D. H.LWW/AENJ LWWJ302-08 January 20. Johnson. M. REFERENCES American College of Emergency Physicians. 5– 26. L. Addiction: Part II. The ACEP recognizes the importance of effectively managing ED patients who are experiencing pain and supports the following principles: • ED patients should receive expeditious pain management. much can be done to improve the care of patients in pain. Annals of Emergency Medicine. ∗ Approved by the ACEP Board of Directors. • Effective physician and patient educational strategies should be developed regarding pain management. Medicine & Ethics. T.. (2004). M. . Weaver. Develop a local policy for the management of acute and chronic pain 2.). W. Parran. D. ED providers need to refine the approach to the problem of pain and substance abuse and reduce the current large amount of variability in our practices.. Educate ED providers and nurses in the topic of pain evaluation and treatment veloped while promoting quality to achieve these goals (Todd. Todd. & Schnoll. J. (2004). Journal of Law. A. Vukmir. A. Consult with pain management or addiction specialists for patients with identified narcotic abuse issues in the emergency department (ED) 4. Identification and management of the drug-seeking patient. • ED policies and procedures should support the safe utilization and prescription writing of pain medications in the ED. March 2004. 2007 22:12 Char Count= 0 40 Advanced Emergency Nursing Journal Table 3. E. • Hospitals should develop unique strategies that will optimize ED patient pain management using both narcotic and nonnarcotic medications. avoiding delays such as those related to diagnostic testing or consultation. ACEP policy statement: Pain management in the emergency department. 16(3). S. (2004). Minkel. J. Beauchamp. R. J.). • Ongoing research in the area of ED patient pain management should be conducted. & Kinsey. Principles and practice of pain medicine (2nd ed. & Humphreys. (2000). 30(33). 2023–2031. H. K. C. Oliva.. Horst.. American Family Physician.. Drug and Alcohol Dependence. Chronic pain and aberrant drugrelated behavior in the emergency department. American Journal of Drug and Alcohol Abuse. 2005). Standards for excellence in pain practice and substance abuse interventions need to be deTable 4. ED providers regarding pain management (Table 4). 2551– 2575. Jr. F. American College of Emergency Physicians (ACEP) policy statement on pain management in the emergency department (ED)∗ The majority of ED patients require treatment for painful medical conditions or injuries. 73(71). Drug seeking behavior. Longo. Journal of Pain & Palliative Care Pharmacotherapy.. Opioid treatment of chronic pain in patients with addiction. Pain management recommendations 1.