a challenging case of chronic pain

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LWW/AENJ LWWJ302-08 January 20, 2007 22:12 Char Count= 0

Advanced Emergency Nursing Journal

Vol. 29, No. 1, pp. 3540

Copyright c 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins

CasesO F N O T E

Column Editor: Karen Hayes

A Challenging Case of Chronic Painin the Emergency DepartmentMedical and Ethical Issues

of ManagementCourtney 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 careand are often faced with the challenge of managing patients with chronic pain. Some of thesepatients present with drug-seeking behaviors that make it difficult to provide appropriate care fortheir condition. This article presents a case of a patient with chronic migraine headache, and theethical issues surrounding her management in an ED, with focus on the patients autonomy, andthe concepts of nonmalficence, beneficence, and informed consent. This article concludes withrecommendations for ED to appropriately and safely manage patients with chronic pain. Keywords:autonomy, beneficence, chronic pain, drug-seeking behavior, ethical issues in emergency care,informed consent, nonmalficence

Mrs H was a 45-year-old woman be-ing treated for migraine headachesby a psychiatric neurologist after

other organic problems had been ruledout. Her oral medication regimen includedgabapentin, topirimate, and propranolol for

headache prophylaxis and oxycodone forbreakthrough headaches. When necessary,her physician administered intramuscular in-jections of meperidine and hydroxyzine for

From the Robert Wood Johnson University Hospital,Hamilton, NJ; and the School of Nursing, ColumbiaUniversity, New York, NY.

Corresponding author: Courtney Reinisch, MSN, RN,APN-C, School of Nursing, Columbia University, NewYork, NY 10032 (e-mail: [email protected]).

breakthrough pain. The patient and her physi-cian had a contract stating she would onlytake the narcotic medications that he pre-

scribed and she would not go to the emer-gency department (ED) for pain medications.Mrs H had been employed as a licensed practi-cal nurse, however, because of her condition,her license had been suspended.

Mrs H did not maintain her contract. Shevisited multiple EDs, requesting pain medi-cations including meperidine and hydromor-phone. If the first ED provider refused treat-ment with narcotics, she would go to the next

local ED and demand the same medications.According to Mrs Hs spouse, she also ob-tained narcotics illegally.

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After several years, the patient and hertreating physician agreed that she needed re-habilitation for her narcotic addiction, and

she attended an inpatient program. Upon dis-charge, she relapsed and resumed her pre-vious behavior, visiting local EDs demanding

narcotic pain medications.The staff within our ED recognized the se-

rious nature of her condition and developed aplan to contact her treating physician at eachvisit. Her physician recommended that we in-ject the patient with saline and tell her wewere giving her meperidine, which was thepractice in his office. The ED staff felt thiscourse of action was dishonest, unethical, andillegal.

Given the treating physicians recommen-dation to use a placebo, managing thepatients condition in the ED remained a chal-lenge. The patients aggressive behavior esca-lated. She threatened to harm members of theED staff if they would not treat her with nar-cotic pain medications. She displayed manip-ulative behavior by requesting to be seen byproviders she believed would treat her withher drug of choice. These providers complied

with her demands to facilitate her dischargewithout incident from the ED. When advisedthat she could not select her provider in the

ED, she would leave before being seen, andsubsequently file a complaint stating she wasnot being treated fairly because her requestto be seen by a particular physician was nothonored.

The patients behavior and frequent vis-its were a source of contention for ED

providers. Some providers would treat MrsH with whatever medication she requested,while others refused to treat her with nar-cotics due to her addiction and worseningcondition and violation of contract with herneurologist.

The patients clinical status continued todeteriorate. Her speech was slurred. Shewalked with a shuffling gait, and had tremors.Given her presentation, some providers re-

fused to evaluate this patient, leaving her tobe seen by another provider. The patient didnot want to be treated by the advanced prac-

tice nurses because she felt they were lesslikely to treat her with narcotics. The ad-vanced practice nurses, as a group, felt that

treatment with narcotics was not in her bestinterest, and would cause more harm thangood.

Current guidelines on appropriate treat-ment of pain in the ED further impacted thispatient care dilemma. The Joint Commissionon Accreditation of Healthcare Organizationsstates that pain is undertreated and mandatespain be assessed as the fifth vital sign. Accord-ing to the commission, a provider must be-lieve a patient to be experiencing the level ofpain he or she reports and to treat the painappropriately.

The patients behavior compelled our EDpersonnel to examine the ethical issues sur-rounding this case. The issues of pain man-agement in the presence of addiction neededto be discussed in relation to the ethical prin-ciples of autonomy, nonmalficence, benefi-cence, and informed consent. The hospitalsrisk management team and the patients neu-rologist were consulted to determine whatcould ethically and legally be done for this pa-

tient since EDs are required to stabilize everypatient that enters the department regardlessof sex, race, medical condition, and ability to

pay.As a result of the meetings, risk manage-

ment and the ED staff reached an agree-ment. The following actions were taken. Acertified letter was sent to the patient advis-ing her that ED personnel would no longertreat her migraines with narcotic medications.

She would be evaluated and treated withthe nonnarcotic headache medications rec-ommended by her neurologist. This decisionwas based on the premise that emergencycare is episodic in nature and treatment ofher condition required specialized manage-ment from a headache or pain specialist. Allproviders in the ED signed the letter. Theletter was carefully worded to ensure thatthe patient understood she was welcomed

in the department, but that narcotics wouldno longer be administered for this particularcondition.


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JanuaryMarch 2007 r Vol. 29, No. 1 Chronic Pain in the Emergency Department 37

DISCUSSION OF CONTEXT AND ETHICALPRINCIPLES

Drug-Seeking Behavior for Pain Management

Pain is the most common presenting com-plaint to a physicians practice (Weaver &Schnoll, 2002). Pain can be classified asacute, lasting from time of injury to 2 weeks;subacute from 2 weeks to 3 months; andchronic, lasting beyond 3 months (Vukmir,

2004). Chronic pain is defined as persistentor episodic pain of a duration or intensity thatadversely affects functioning and well-beingof the patient attributable to any nonmalig-nant etiology (Vukmir, 2004). Chronic, non-malignant pain accounts for 10% to 16% of

outpatient visits and 25% to 40% of hospital-izations (Weaver & Schnoll, 2002).

Pain drives drug seeking for opioids in bothanimals and humans. This causes increased

drug-seeking behaviors and cravings in pa-tients with substance use disorders (Trafton,Oliva, Horst, Minkel, & Humphreys, 2004).Pain is often associated with mental healthproblems and functional and social disabil-ity. Patients in pain have increased rates ofdepression, anxiety, suicidal ideation, and hal-lucinations. Depression rates increase withincreasing rates of pain (Trafton et al., 2004).

Problematic behaviors such as health com-plaints, decreased physical function, illicitdrug use, mood disorders, healthcare uti-lization, and suicidal ideation all increasewith pain. Pain intensity may be a drivingforce behind undesirable patient behaviors(Trafton et al., 2004).

Drug-seeking behavior occurs with bothactive addiction and pseudoaddiction. Drug-seeking behavior for pain relief is definedas pseudoaddiction. This behavior will in-

crease if pain is not adequately controlled.To avoid pseudoaddiction, providers must be-lieve patient complaints are legitimate. Ini-tially, it is nearly impossible to distinguish be-tween an addict who seeks increasing levelsof pain medications for euphoria comparedwith a patient in pain who has undertreatedpain. Once pain is appropriately managed,providers can distinguish between addic-

Table 1. Drug-seeking behaviors

1. Multiple visits

2. The inability to focus on anything otherthan the medication

3. Lost prescriptions

4. A primary provider that is not available

5. Allergy to alternative medications

6. A desires for narcotics

7. Substitutes benzodiazepines

8. Common complaints include headache,

ureteral colic, toothache, and abdominal

pain

9. Pain is described as unbearable

10. Overly creative requests

11. Appearance change or use of alias

Note. Adapted from Vukmir (2004).

tion and pseudoaddiction (Weaver & Schnoll,2002).

Patients demanding behavior to obtain

medications can cause them to claim an al-lergy to nonaddictive medications, report ahigh tolerance to drugs, may lose a nar-cotic prescription, or claim to run out early.Doctor shopping is another common drug-seeking behavior where the patient sees mul-tiple providers to obtain an adequate or

increasing supply of prescription narcotics.These patients are often seen in EDs, afterhours, or reporting that they are from out

of town (Longo, Parran, Johnson, & Kinsey,2000). Patients with drug-seeking behaviorsmay present with a variety of complaints or re-quests, as identified in Table 1 (Vukmir, 2004).

Assessment and treatment of pain in the EDis unique and presents challenges. Problemcategories include patients with chronic painwho need specialized follow-up and do notbenefit from additional analgesics given in theED. It may be difficult to assess and identify

those who seek and abuse drugs within theED setting (Vukmir, 2004).

Depression, hospitalizations, and suicidalideation improve with adequate pain control.Appropriate pain management may help pa-tients with substance use disorder to con-trol their illicit substance use (Trafton et al.,


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2004). Dissatisfaction with pain managementis more likely with more severe pain, as wellas higher rates of depression, anxiety, and al-

tered mental status (Vukmir, 2004). Pain man-agement is difficult because it relies on subjec-tive data with little objective support. There

is a greater success in managing pain with along-term patient relationship as opposed tothe brevity of an ED visit (Vukmir, 2004).

Given the high prevalence of chronic painand the limited availability of pain manage-ment resources, particularly for populationsserved by the ED, pseudoaddiction is themost likely cause for a large proportion ofdrug-related behaviors deemed aberrant. Pa-tient reports of distress associated with un-

relieved symptoms, aggressive complainingabout the need for higher doses, and patientdose escalation are signs of pseudoaddiction.The hallmark of pseudoaddiction is that aber-rant behaviors disappear when adequate anal-gesics are given to control pain (Todd, 2005).Table 2 illustrates behaviors more or less con-sistent with addiction.

Autonomy

Personal autonomy is defined as self-rule thatis free from both controlling interference by

others and from limitations such as inade-quate understanding that prevents meaning-ful choice (Beauchamp & Childress, 2001).

Autonomous persons with self-governing ca-pacities sometimes fail to govern themselvesin particular choices because of temporaryconstraints caused by illness or depression orbecause of ignorance, coercion, or other con-ditions that restrict their options (Beauchamp& Childress, 2001). Respect for autonomy isa professional obligation in healthcare, andautonomous choice is a right of patients(Beauchamp & Childress, 2001).

Although Mrs H continued to be au-tonomous, she ceased to be able to makedecisions that were in her best interest dueto her worsening condition. She was impairedbecause of her drug-seeking behavior, and dis-abled as a result. She was unable to be anactive participant in her care due to her de-

Table 2. Spectrum of aberrant drug-relatedbehaviors that raise concern about the poten-tial 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, in the family, or socially

Repeated resistance to changes in therapy

despite evidence of drug effects

Note. From Opioids for Nonmalignant Pain: Issues and

Controversy, by C. L. Shalmi (cited in Warfield & Bajwa,

2004).

sire to reach her goal of obtaining her drug ofchoice. It is reasonable to question whethertreating this patient in the ED also contributedto her drug-seeking behavior and addiction.Some providers who would treat her with


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JanuaryMarch 2007 r Vol. 29, No. 1 Chronic Pain in the Emergency Department 39

increasing doses of narcotics reinforced thepatients behaviors. In addition, those whowould not treat her and put her into with-

drawal may have increased her pain.

Nonmalficence and Beneficence

The concept of nonmalficence can be de-fined as the obligation to intentionally dono harm, whereas beneficence can be de-fined as the obligation to promote or do good(Beauchamp & Childress, 2001). Generally,healthcare providers are caring individuals at-tempting to keep their patients from receiv-ing harmful treatments while providing bene-

ficial care to their patients.In Mrs Hs case, it was difficult to de-

termine which treatment would deliver thegreatest benefit without causing harm. Someproviders felt that treating her pain wouldbe harmful for her condition, thus worsen-ing her drug-seeking behaviors. Other care-givers felt that providing narcotic pain treat-ment in the acute arena would be the onlyreasonable choice. She would receive tempo-

rary pain relief and avoid withdrawal symp-toms. The question in this patients manage-ment was whether the healthcare providerscaused her harm by treating her with nar-

cotics, a contributing factor to her present-day addictive behaviors. Obviously, the out-come was not intentional. Providers wouldhave not prescribed narcotics if they thoughtthis patient would become addicted. This wasan unfortunate outcome of attempting to ben-

efit the patient by offering pain relief. Overtime, what was once a beneficial treatmentbecame a detriment.

Informed Consent

When initiating the prescription for nar-cotic pain medications, patients need to

be informed of the potential for physicaldependency, as well as the possibility ofmild-to-moderate rebounding when themedication is discontinued (Longo et al.,2000). An informed consentis an individualsautonomous authorization of a medicalintervention (Beauchamp & Childress, 2001).

Informed consent is obtained in some con-text for medicines for which shared decisionmaking is not possible.

Mrs H was unable to truly give informedconsent for any treatment because she was of-ten under the influence of a variety of sub-

stances. She was driven to obtain narcoticsthat did not allow her to consider risks andbenefits of treatment. Participation in her carewas not a motivation. Healthcare providerslost objectiveness due to her escalating drug-seeking behaviors.

Emergency Department Management

Given the volume of patients with substance

abuse disorders, the ED is an appropriate sitefor screening and intervention for both alco-hol and drug problems. However, some EDproviders receive limited training in recogni-tion and appropriate interventions for suchproblems (Todd, 2005). Emergency care is

episodic by design, with multiple providersproviding care. These patients require closeobservation and treatment by pain specialistsor drug addiction specialists, depending uponthe particular case. Close attention needs tobe paid to these patients to ensure that theyreceive the specialized level of care they de-

serve (Todd, 2005). Therefore, what shouldEDs do when faced with these patients? Thereis paucity of treatment guidelines and best

practice standards for ED pain care, in part,because there is a lack of research in this areaby emergency medicine investigators (Todd,2005). However, the American College ofEmergency Physicians (ACEP) offers a policystatement for pain management in the ED(ACEP, 2004) (Table 3).

Our profession should abandon the termdrug-seeking behavior, since for the patient inpain, seeking an analgesic is the height of ra-

tionality. Aberrant drug-related behaviors asthe term suggests is a broad range of behav-iors that are acceptable in the context of paintherapy (Todd, 2005). On the basis of researchin this topic, recommendations for futurecases may include developing local policies,patient referral, and consult, and educating


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Table 3. American College of Emergency Physicians (ACEP) policy statement on pain manage-ment in the emergency department (ED)

The majority of ED patients require treatment for painful medical conditions or injuries. TheACEP recognizes the importance of effectively managing ED patients who are experiencing

pain and supports the following principles:

ED patients should receive expeditious pain management, avoiding delays such as those related

to diagnostic testing or consultation.

Hospitals should develop unique strategies that will optimize ED patient pain management using

both narcotic and nonnarcotic medications.

ED policies and procedures should support the safe utilization and prescription writing of pain

medications in the ED.

Effective physician and patient educational strategies should be developed regarding pain

management, including the use of pain therapy adjuncts and how to minimize pain after

disposition from the ED.

Ongoing research in the area of ED patient pain management should be conducted.

Approved by the ACEP Board of Directors, March 2004.

ED providers regarding pain management(Table 4).

Since relieving pain and reducing sufferingare primary responsibilities of EDs, much canbe done to improve the care of patients inpain. Providers have a duty to limit the per-sonal and societal harm that can result fromprescription drug abuse. ED providers needto refine the approach to the problem of pain

and substance abuse and reduce the currentlarge amount of variability in our practices.Standards for excellence in pain practice andsubstance abuse interventions need to be de-

Table 4. Pain management recommenda-

tions

1. Develop a local policy for the

management of acute and chronic pain

2. Refer patients with chronic pain

syndromes to pain management

specialists for outpatient management3. Consult with pain management or

addiction specialists for patients with

identified narcotic abuse issues in the

emergency department (ED)

4. Educate ED providers and nurses in the

topic of pain evaluation and treatment

veloped while promoting quality to achievethese goals (Todd, 2005).

REFERENCES

American College of Emergency Physicians. (2004).ACEP

policy statement: Pain management in the emergency

department. Annals of Emergency Medicine, 44(2),

198.

Beauchamp, T. L., & Childress, J. F. (2001). Principles of

biomedical ethics(5th ed.).New York:Oxford Univer-sity Press.

Longo, L. P., Parran, T., Jr., Johnson, B., & Kinsey, W.

(2000). Addiction: Part II. Identification and manage-

ment of the drug-seeking patient. American Family

Physician, 61(8), 24012408.

Todd, K. H. (2005). Chronic pain and aberrant drug-

related behavior in the emergency department. Jour-

nal of Law, Medicine & Ethics, 33(4),761769.

Trafton, J. A., Oliva, E. M., Horst, D. A., Minkel, J. D.,

& Humphreys, K. (2004). Treatment needs associated

with pain in substance use disorder patients: Implica-

tions for concurrent treatment. Drug and Alcohol De-

pendence, 73(71), 20232031.

Vukmir, R. B. (2004). Drug seeking behavior. American

Journal of Drug and Alcohol Abuse, 30(33), 25512575.

Warfield, C. A., & Bajwa, Z. H. (2004). Principles and

practice of pain medicine (2nd ed.). Columbus, OH:

McGraw-Hill.

Weaver, M. F., & Schnoll, S. H. (2002). Opioid treatment

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a challenging case of chronic pain

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