The article entitled, “New U.S. Campaign Targets Prescription Drug Abuse, Especially Painkillers,” (EMN May 2001, p. 1) highlights a frequent dilemma that emergency physicians face. On one hand, real pain needs appropriate pain relief, possibly opioids. But on the other, the EP is particularly vulnerable to inappropriate drug-seeking patients. The “never seen, never see again” patients make it hard to differentiate patients with true pain from those with secondary gain. The dilemma is made even more vexing because of increased attention the JCAHO is giving to pain evaluation and treatment.
At the University of Cincinnati Center for Emergency Care, an evidence-based guideline has been introduced for the complaint of toothache, a common complaint used by drug seekers. This guideline was written after a thorough literature search for trials comparing various agents to relieve dental pain as well as consultation with dental experts. The guideline provides clear guidance on the use of various pain relief medications including opioids. It has been well received by our EP staff, and has noticeably changed the pattern of toothache complaints. A second guideline for back pain, also evidence-based, recently has been introduced as well.
The evidence-based approach to pain relief not only ensures that patients receive appropriate pain and symptom relief, but also provides the EP with much appreciated support in those all too uncomfortable interactions when the patient's intent is to receive inappropriate opioids or other controlled substances.
Alexander Trott, MD