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Viewpoint: Humane and Correct Treatment for Pain

Mosley, Mark, MD

doi: 10.1097/01.EEM.0000547707.57097.f0

Dr. Mosley is the medical director for student and resident education at Wesley Medical Center in Wichita, KS.

Effective and rapid pain management is what emergency physicians do best. We may, however, harm patients on rare occasions by enabling opioid misuse or allowing more chronic opioid use. Many emergency physicians have defaulted to a popular simplified strategy in response to the opioid crisis: Use fewer opioids so they don't create opioid addiction and make the opioid crisis worse.

Truth is complex. Making it simple makes it wrong. A one-size-fits-all approach to pain control in the ED can be cruel to patients needing opioids. Our response should not be “I start with a nonopioid approach.” Neither should it be “I usually don't write opioid prescriptions, but when I do, I never write for more than 12.” These stances are not evidenced-based. They are not even rational. Rather, we should ask, “In which patients should I take these approaches?” and “For what purpose am I using fewer opioids?”

One of the key recommendations in the 2017 document by the Johns Hopkins Bloomberg School of Public Health and the Clinton Foundation, The Opioid Crisis—From Evidence to Impact, was to develop evidence-based criteria to identify patients at high risk for opioid misuse. ( One risk-stratifying tool EPs can use is CAPE. The evidence from this comes from multiple sources, including literature on addiction, opioid-naive post-op patients, and ED chronic pain and misuse. (JAMA Intern Med 2016;176[9]:1286;; JAMA Surg 2017;152[6]:e17050;; J Am Board Fam Med 2017;30[4]:407;; Pain Rep 2017;2[4]:e606;; N Engl J Med 2016;374[13]:1253;; BMJ 2018;360:j5790; CAPE stands for:

Chronic pain (may or may not currently be on opioids)

Addiction (nicotine, alcohol, benzodiazepines, opioids, and others)

Psychiatric (depression, anxiety, schizophrenia, bipolar, ADHD in teens)

Electronically flagged (prescription drug monitoring, excess ED visits)

This information is readily available on every patient in the ED. This is an intuitive, easy, and routinely available tool one could use now (or for retrospective chart review). These high-risk factors for chronic opioid use, opioid misuse, and addiction are born out consistently and repeatedly in multiple studies, but they have never been used as a risk-stratifying tool in the ED. These likelihood ratios (LR) for some elements are found in CAPE: substance abuse history (LR 4.54); chronic pain history (LR 1.68-2.42), tobacco use (LR 1.97- 2.36), benzodiazepine use (LR 1.6-1.9), depression (LR 1.44-1.78), and in one study, bariatric surgery (LR 1.77-2.72).

CAPE is not weighted or graded, though future research might support a more detailed scoring system. The patient is CAPE-positive if any elements are present and CAPE-negative if no elements are present.

CAPE is not a standalone tool. One of the primary considerations is whether a patient has pain that is objective (deformed wrist, distended abdomen, etc.) or whether the patient has pain that is purely subjective (tooth pain with no visible swelling, headache, or nonspecific low-back pain, etc.). A CAPE-positive patient with only subjective symptoms may be treated quite differently from a CAPE-positive patient with an obvious acute objective injury. There is no reason not to use opioids when there is a CAPE-negative patient with an obvious objective acute painful condition, as long as the patient shares this approach and has transportation home.

Why use CAPE? It removes potential bias from our gestalt. It objectively documents why we do not initiate opioids in a few select situations. But perhaps more importantly and even heroically, using CAPE allows us to treat the majority of normal low-risk patients with acute objective pain humanely and correctly.

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