How to Survive Your Next Trip to the Emergency Room

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By R Carter

This post is based primarily on guidelines which are used in the state of Ohio but have relevance for chronic pain patients in any state.

Ohio has been a leader at implementing prescribing guidelines for opiates used in treating acute and chronic pain. While the guidelines still reflect an excessive amount of caution in my opinion, they are balanced enough to allow healthcare professionals, more specifically primary care providers to whom the guidelines are directed, to exercise professional judgement in treating and exceeding guidelines when warranted. This should be sufficient reassurance for prescribers to return to rational decision making, i.e. willingness of PCP’s to treat chronic pain as well as exceeding guidelines with patients who fall outside opiate naive norms. By following these guidelines PCP’s are now protected from fines and the threat of sanctions on their license, providing a measure of protection which they’ve not had since 2016, still few if any have returned to treating chronic pain patients.

But the guidelines are still lacking and need further refinements for situations where chronic pain patients experience acute pain scenarios such as surgery, accidents and exacerbations of existing medical conditions. The current guidelines listed below, still follow the perspectives adopted after the 2016 CDC Guidelines. The chronic pain community should add to their call list the State Medical Board of Ohio, urging policy makers to revise the OOCS (ohio opioid and controlled substance) guidelines to reflect the more rational guidelines now in place for acute and chronic pain.

When chronic pain patients present to an ER with an injury or an exacerbations of an existing condition they are still routinely turned away and for no other reason than, they are currently treated with opiates. As any healthcare professional knows, long term use of opiates results in physical tolerance to the medication. This is the reason why abusers continue to raise the dosage as they abuse. The misplaced fear that giving more pain medication to a chronic pain patient with an acute pain problem somehow puts them at risk for abuse is both irrational and misguided. In the absence of a documented history of abuse, such actions are in fact in conflict with the training healthcare professional receive in school, assuming they themselves were not asleep during those classes.

These facts remain and are continually ignored by healthcare providers.

  • Tolerance to opiates in chronic pain patients is not a sign nor proof of addiction or abuse.
  • The development of tolerance is proof that in an acute pain scenario the caps and limits need to be higher to account for this tolerance.
    • Medical fact, patients with a tolerance are at less risk for an overdose when treated by an ER physician, not more.
    • An opiate naive individual in an acute care setting is at a higher risk for overdose because they do not have a tolerance to controlled substances.
    • Every healthcare provider has been taught, patients with a tolerance to a controlled substance will always require larger amounts in an acute care setting. This has been taught as a standard of care for more than 100 years, long before an opiate crisis.
  • In the absence of a documented history of abuse, particularly for patients who have been on opiates for more than a year, the risk of abuse is minimal. This fact has been documented in several studies done on the long term use of opiates.
  • The 2016 CDC Guidelines for Chronic Pain acknowledge
    • The use of other controlled substance for short periods of time, in combination with opiates can be done safely when the prescriber is fully informed of a patients current medications and medical conditions.
    • With most states having implemented a PDMP, access to such information is now immediately available online from a computer for any ER physician.
  • Current standards of care for patients who have been on opiates for more than a year, include a full work up which includes urinalysis and a full exam only once every 6-12 months. This recommendation is based on the fact that the risk for abuse is very low for patients after one year of successful pain management treatment.
  • Recommendations to avoid IM or IV pain medication for chronic pain patients in an acute care setting has no basis in evidence based medical treatment. Such recommendations are a throw back to fear based ignorance and as such need to be eliminated until scientific evidence exists to support such actions.
  • Denying medication to patients who present to the ER due to multiple exacerbations of a condition is both in humane and is born out of fear based ignorance which has no scientific data to support it.
  • ER staff who deny pain medication during an acute injury or exacerbation of a condition, must be able to give medical justification on why such action would put a patient’s health at greater risk than the underlying acute problem.
    • Citing abuse as a potentially greater risk is not a triageable risk factor in an acute care setting, it is a long term risk and in the absence of an abuse history, an unjustifiable assumption.

These are the current OOCS guidelines in Ohio which need to be revised.

  1. OOCS for acute pain, chronic pain and acute
    exacerbations of chronic pain will be prescribed in
    emergency/acute care facilities only when appropriate
    based on the patient’s presenting symptoms, overall
    condition, clinical examination and risk for addiction.
    1. Doses of OOCS for routine chronic pain or
      acute exacerbations of chronic pain will
      typically NOT be given in injection (IM or IV)
      form.
    2. Prescriptions for chronic pain will typically
      NOT be provided if the patient has either
      previously presented with the same problem
      or received an OOCS prescription from
      another provider within the last month.
    3. IV Demerol (Meperidine) for acute or chronic pain is
      discouraged.
  2. Emergency medical clinicians will not routinely provide
    1. Replacement prescriptions for OOCS that were lost,
      destroyed or stolen.
    2. Replacement doses of Suboxone, Subutex or
      Methadone for patients in a treatment program.
    3. Long-acting or controlled-release opioids (such as
      OxyContin, fentanyl patches, and methadone).
  3. Prior to making a final determination regarding
    whether a patient will be provided a prescription for
    OOCS, the emergency clinician or facility:
    1. Should search the Ohio Automated Rx
      Reporting System (OARRS) database
      (https://www.ohiopmp.gov/portal/Default.asp
      x) or other prescription monitoring programs,
      per state rules.
    2. Reserves the right to request a photo ID to
      confirm the identity of the patient. If no photo
      ID is available, the emergency or other acute
      care facility should photograph the patient for
      inclusion in the facility medical record.
    3. Reserves the right to perform a urine drug
      screen or other drug screening.
  4. Emergency/acute care facilities should maintain an
    updated list of clinics that provide primary care and/or
    pain management services for patients, as needed.
  5. Prior to making a final determination regarding whether a patient will be provided a prescription for an OOCS, the emergency clinician should consider the following options:
    1. Contact the patient’s routine provider who usually prescribes their OOCS.
    2. Request a consultation from their hospital’s palliative or pain service (if available), or an appropriate sub‐specialty service.
    3. Perform case review or case management for patients who frequently visit the emergency/acute care facilities with pain‐related complaints.
    4. Request medical and prescription records from other hospitals, provider’s offices, etc.
    5. Request that the patient sign a pain agreement that outlines the expectations of the emergency clinician with regard to appropriate use of prescriptions for OOCS.
  6. Emergency/acute care facilities should use available electronic medical resources to coordinate the care of patients who frequently visit the facility, allowing information exchange between emergency/acute care facilities and other community‐care providers.
  7. Except in rare circumstances, prescriptions for OOCS should be limited to a three‐day supply. Most conditions seen in the emergency/acute care facility should resolve or improve within a few days. Continued pain needs referral to the primary care physician or appropriate specialist for re‐evaluation.
  8. Each patient leaving the emergency/acute care facility with a prescription for OOCS should be provided with detailed information about the addictive nature of these medications, the potential dangers of misuse and the appropriate storage and disposal of these medications at home. This information may be included in the Discharge Instructions or another handout.
  9. Following the medical screening, emergency/acute care facilities should provide a patient handout that reflects the above guidelines and clearly states the facility position regarding the prescribing of opioids and other controlled substances.

For chronic pain patients who live in Ohio, these guidelines should be printed out and carried with you at all times. In situations where you are required to go to an ER, knowing what the facility and the ER physician is required to do, is valuable information that can make the difference between being sent home denied of any care and being treated first for your medical conditions and secondly for the fact that you are a chronic pain patient. These an other strategies are tools the chronic pain community can use to improve their chances on being treated responsibility.

Chronic pain patients should always stress with ER staff that your presenting problem, not the fact that you use opiates, is what they are required to address and that denying medical care based on the single fact that you are taking opiates is questionable, possibly life threatening and can have liability consequences.

 

 

 

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