Ask emergency physicians where their greatest job stress comes from, and it is unlikely they will name the trauma, violence, or death that are a part of this vocation. Instead, frustration and fatigue come from the barrage of daily visits from patients seeking relief from pain.
Drug-seeking behavior, doctor shopping, and prescription scams are all concerns for emergency physicians as they treat legitimate pain without enabling these behaviors. (Med Clin North Am 1997;81:967.) EDs with 75,000 patients per year can expect up to 262 visits per month from patients fabricating their need for opioids. (Emerg Med Clin North Am 2005;23:349.)
A leading cause of investigation and actions against physician licenses is allegations of over-prescription of controlled substances. (Am Fam Physician 2000;61:2401.) Studies of chronic pain patients have found that opioids have little benefit and may lead to harm, including higher health care utilization and lower activity levels. (Pain Physician 2007;10:399.) Physicians have an obligation to prescribe controlled substances for legitimate purposes, but the nature of the ED does not allow for adequate follow-up care. The prevalence of illicit drug dependence or abuse rose for opioids in 2002 to second place, surpassing cocaine and heroin. (J Law Med Ethics 2005;33(4):770.)
Therapeutic contracts have been used for chronic administration of opioids, but the efficacy of this practice has not been established. Great variability can be found in contract forms, although most seem to improve adherence to treatment through education, clearly setting limits, and sharing administrative information. (Clin J Pain 2002;18[4 Suppl]:S70.) Contracts that include random drug testing have been accused of being unenforceable, creating stigma, and destroying patients’ trust, which reduces adherence to treatment. (Clin J Pain 2002;18[4 Suppl]:S70; J Law Med Ethics 2009;37:841.)
To address these issues, Kootenai Medical Center, a 246-bed acute care hospital, designed a pain care management program in 2006. Mr. Masterson identified reducing repetitive visits for patients with pain as his primary task when he began as the ED's first case manager, and led the collaborative effort that included input from physicians, nurses, social workers, occupational health, and addiction and pain specialists. When the program was initiated, the ED saw 48,949 patients per year, 36 percent for pain or pain-related complaints. Physicians were spending 19.5 hours of their day with these patients.
The goals of the program were agreed on by the interdisciplinary team:
- Manage patients with chronic pain or pain-related complaints by coordinating care between the patient's primary physician and the ED.
- Support the treatment goals of the primary physician without encumbering the emergency department.
- Use non-narcotic pain relief whenever possible, and as a standard of care for treating headaches.
- Provide the best care for the patient for his presenting condition.
Improving communication between primary care providers in the community and emergency physicians was identified as a significant goal. Coordination seemed imperative, and was accomplished by inviting primary care physicians to the bimonthly interdisciplinary meetings where each patient in the program is evaluated and plans of care are created. The goal was to avoid having patients denied narcotics in the ED from seeking them from other health care providers, switching the burden from one facility to another.
Other strategies included linking communication through electronic health records with most major health care facilities within a 150-mile radius. Computerized prompts alerted staff members in any participating emergency department that the patient was enrolled in a pain care management program, and detailed the individual's plan of care. Interventions were described, such as restriction of narcotics, non-narcotic treatment protocols, use of one retail pharmacy and one provider, and involvement with chemical dependency programs. Relationships were developed in the region with the Washington ED Opioid Abuse Work Group, along with pain clinics and chemical dependency units that assisted in developing the program. Emergency physicians gained access to Idaho's prescription monitoring system to investigate the number of prescriptions filled for any patient in the state.
A retrospective study conducted in 2009 found that ED visits were reduced by 77 percent for the study pool, from 3,689 visits in the year before the program and 852 in the year after. The findings support continuing the program. Because more than 70 percent of patients enrolled in the program had insurance plans that pay less than full value (Medicare 22%, Medicaid 23%, self-pay or no pay 34%), cost savings for the post-program year were estimated at $7.5 million.
A key component of the program is referring patients to a primary care provider, and the percentage of those in the program with a primary care provider rose from 42 percent to 89 percent. Ongoing monitoring by a primary care provider is seen as essential in managing pain-related health issues appropriately in the ED, and keeping patients from visiting multiple providers to seek narcotics. This strategy has been mutually beneficial for primary care providers, as shown by the increased number of referrals to the pain care management program coming from primary care providers themselves.
Besides benefit in finances and patient visits, less measureable gains have been achieved. Physicians and nurses said they are more satisfied with their workplace with the plan in place to address this difficult patient population. Employee survey satisfaction scores have steadily improved since the program began, too.
Since inception, more than 2,000 patients have been monitored, resulting in fewer repetitive and potentially ineffective ED visits. Regular planning meetings continually refine this program, and assess the benefit to patients and the organization. The full payoff for the program's efforts can only be surmised, and may be far-reaching; no one knows how reducing available opioids in the community may affect addiction rates and crime. But the tangible rewards are clear: reduced burdens of time, costs, and employee stress on ED staff.
Dr. Fooe is an emergency physician, Mr. Masterson is the ED case manager, and Ms. Wilson the clinical research coordinator at Kootenai Medical Center in Coeur d'Alene, ID.
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