Pain and the Emergency Department

What have you learned about the management of pain in the ED, and what pain patients might be at higher risk for poor care?

How are patients with chronic pain disorders treated in the Emergency Department?

Read through the first roundtable of a two part series with 4 experts in the field of pain treatment. Part one deals with experts discussing some of their thoughts on the quality of care pain patients recieve in the Emergency Department.

Alan Witkower, Ed.D.:

Alan Witkower, Ed.D.,is a Psychologist and the Assistant Director, Outpatient Pain Service, Associate in Psychology, Department of Psychiatry, Massachusetts General Hospital, and Instructor in Psychology, Harvard Medical School

My knowledge of the management of pain in the Emergency Department, with the exception of what I have read on the topic, is based on the anecdotal reports from my patients. I treat many patients with intractable pain who are being managed with chronic opioid therapy. Many of these patients will require an occasional Emergency Department visit. Here is an example of a not-uncommon situation.

A patient, who happens to be a minister, has chronic back pain managed with opioid pain medications, and told this story. He had a back spasm on a weekend, likely related to the fact that he recently did a lot of airline travel. He is prone to spasms and his primary care doctor was not available, so his understanding of what to do was to go to his local emergency department. He had a long wait and then spoke with a triage nurse. Initially he thought she was sympathetic, but later he felt she believed his complaint was trivial. When he met with the physician he was asked why his problem couldn’t wait until Monday. The patient explained he was worried that something more seriously wrong was causing the increased pain. He told the physician what medication he had been taking and described what he had tried to do to mitigate the pain. He said his pain was 9/10 instead of his usual 6/10. Unfortunately, (although I counsel patients to always do this) he had not brought any documentation with him. The patient reports that he was given a “cursory” examination and was told he could be given a muscle relaxant. When the patient explained that he might respond better to a temporary increase in his opioid pain medication, he was dismissed with the impression that he was viewed as a “drug-seeker”.

My experience is that the patients who have chronic headache or chronic low back pain and seek emergency care are more likely to be dismissed than patients with other chronic medical and pain disorders. My experience has taught me that weekends are the worst time for patients presenting to the ED with a pain exacerbation. I have read that there are socio-economic and racial biases, which may increase the chance of poor treatment, but in general my patients are white and middle class. While not everyone remembers to do this, I suggest that they bring their pain contract, medicine bottles, and a list of their medications and contact information for their physician, whenever they need to go to an emergency department.