Utilization of the Emergency Department by Chronic Pain Patients to Obtain Pain Medications: A Study...

Utilization of the Emergency Department by Chronic Pain Patients to Obtain Pain

Medications: A Study of Barriers to Treatment, Abusive

Behaviors and Psychological Factors

• Scott M. Fishman, MDChief: Div. of Pain MedicineDept. of Anesthesia & Pain MedicineUC Davis Medical Center

Professor of AnesthesiologyUniv. of California, DavisSchool of Medicine

Background

• Mayday Foundation RFP• ED paper

» Literature review ~ Chronic pain evaluation

• LBP• Headaches• Sickle Cell• Ureterolithiasis

Wilsey, Fishman, Rose, Papazian, Pain management in the ED. Am J Emerg Med 2004; 22: 51-7Wilsey, Fishman, Rose, Papazian, Pain management in the ED. Am J Emerg Med 2004; 22: 51-7

Barriers to Treatment

• Quantitative data» Questionnaires

~ Patients

~ Physicians

~ Nursing staff

• Qualitative analysis » Interviews

~ On perceived barriers to care in the ED from the perspective of physicians

Utilization of the Emergency Department by Chronic Pain

Patients to Obtain Pain Medications: A Study of Barriers to Treatment, Abusive Behaviors

and Psychological Factors

Scott Fishman, MD, Barth Wilsey, MD,

Ingela Symreng, PhD, Dan Mungas, PhD,

Christine Ogden, BS

Overview• Study Structure• Method of Recruitment• Selected Population

~ Patient Demographics

~ Provider Demographics

• Status of Recruited Patients• Successful and Failed Recruitment

Techniques

Study StructureVisit 1

• Subject recruited while they are in the ED to be treated for chronic pain, duration 6 months» Fill out as many questionnaires as possible

~ Demographics, CAGE and Compton/Jameson Questionnaires

» I-S.O.A.P., C.M.S.D., P.B.Q., PDQ-4+, C.S.Q., C.P.S.S., S.E.F., S.E.O.S., STAI, and BDI-II

• Subject given contact information » Advised of a F/U appointment with the

psychologist ~ Scheduled within 14 days after the ED visit

Study Structure Visit 2

• Subject contacted within one week of ED Visit to schedule a F/U visit with psychologist» If all questionnaires are not complete

~ Opportunity at time of F/U visit to complete all questionnaires

» The patient will meet with the psychologist for the S.C.I.D.

» After meeting with the psychologist, the patient is informed about payment for participation

• Completed Subject» A set of complete questionnaires, BDI-II, and S.C.I.D.

evaluation

Method of Recruitment – Academic Offices

• Ability to view the ED “Whiteboard” via remote computer in our Academic Offices enables remote screening

» Research Assistants can utilize computers to look for patients who complain of the following generalized symptoms:

~ Chronic or Mild Stable Pain

~ Chronic Back Pain

~ Headache

~ Earache

~ Rx Refill Request

~ Diffuse Body Pain

~ Vague Abdominal Pain• Students travel to the ED to recruit these identified subjects

Method of Recruitment – ED• Students within the ED have significant access

» Electronic “Whiteboard”, patient charts, and physical “Whiteboard”

» Patients recruited using the inclusion/exclusion criteria designated by the protocol

• Students approach patients within different Areas, including the waiting room, where they will proceed through the following steps:

» Brief introduction to the study» Informed Consent» Administration of Study Questionnaires» Collection of all study materials before student and/or patient

departs from the ED

Continued Contact Post ED Visit

• A Research Assistant will contact subject via telephone within 1 week of the initial ED visit

» At this time, the subject is scheduled to complete Visit 2 within 14 days of the initial ED visit

» The subject is contacted by telephone up to three times before the patient will be discontinued due to lack of compliance

Subject Selection

Inclusion Criteria• Male/Female 18 yrs of age• Patient is being seen at the University

of California Davis ED for Schedule II medications

• Patient has had pain for 6 months or longer prior to enrollment for which schedule II medications are already being prescribed

• Patient presents to the ED with a complaint of vague head, abdomen, or back pain of nonacute onset, diffuse body paint, etc

• Patient is able to read, understand, and voluntarily sign the approved informed consent form prior to the performance of any study specific procedures

Exclusion Criteria• Patient arrived by

ambulance• Patient has an emergency

medical condition• Patient states that they are

not comfortable reading and comprehending English

• Patient is unwilling or unable to comply with the study visit schedule

Patient Demographics: Gender

33

44

0

5

10

15

20

25

30

35

40

45

50

Num

ber o

f Pat

ient

s

Female

Male

n = 77

Patient Demographics: Duration of Chronic Pain

1

5

8

17

45

0

5

10

15

20

25

30

35

40

45

50

< 3 mo 3-6 mo 6mo-1yr 1-5yr 5+ yrs

Duration of Pain

Num

ber o

f Pat

ient

s

n = 76

Patient Demographics: Ethnicity

35

28

10

01

9

0

5

10

15

20

25

30

35

40

White Black American Indian Alaskan Native Asian or PacificIslander

Hispanic

Num

ber o

f Pat

ient

s

n = 83

Patient Demographics: Annual Income

33

16

7 7

31

0

3

0

5

10

15

20

25

30

35

< 10,000 10,001-20,000 20,001-30,000 30,001-40,000 40,001-50,000 50,001-60,000 60,001-70,000 70,001+

Dollars

Num

ber o

f Pat

ient

s

n = 70

Patient Demographics: Education

25

8

24

14

1 1

0

5

10

15

20

25

30

High School GED Some College Graduated college Masters Advanced Degree

Num

ber o

f Pat

ient

s

n = 73

Patient Demographics: Employment

18

55

0

10

20

30

40

50

60

Num

ber o

f Pat

ient

s

Employed

Not Employed

n = 73

Types of Employment• Currently Employed : Line of Work

~ Building Maintenance

~ Scrub Technician

~ Construction

~ Testing Technician

~ Stock Worker

~ Telemarketer

~ Editor

~ Housekeeper

~ Receptionist

~ Physical Therapist

~ Luggage Handler

~ Drug and Alcohol Counselor

~ Customer Service Clerk

~ Environmental Manager

~ Wildland Firefighter

~ Mental Health Worker

~ Writer

~ Cable

~ Truck Driver

~ Musician

• Currently Unemployed: Longest Employment~ Fence Builder ~ Cable

~ Presser/Dry Cleaner ~ Dock worker

~ Retail Management ~ Contractor

~ Engineering Technician ~ Housekeeping

~ Insurance ~ Janitor

~ Figure Skater ~ Painter

~ Analytical Chemistry ~ Roofing

~ Asst. Supervisor for Distrib. ~ Lumberjack

~ Homemaker ~ Homemaker

~ Nursery Employee ~ Truck Driver

~ Underground Construction ~ Cashier

~ Limousine Company ~ Army

~ Restaurant Work ~ Cook

~ Bakery Machine Operator ~ Healthcare Research

~ Fast Food Customer Service ~ Cabinet Worker

~ Warehouse Worker ~ Plumbing/Electrical

~ Operating Engineer Miner ~ Computer Programmer

~ Office Furniture Installer ~ Mechanic

~ Mental Health Case Mgr. ~ Welder/Fabricator

~ Accounting ~ In House Security

~ Sales

Provider Demographics

Provider Demographics: Different Providers

14

5

36

1

0

5

10

15

20

25

30

35

40

Attending Resident Nurse Nursing Student

Nu

mb

er

of

Pro

vid

ers

n = 56

Provider Demographics: Gender

25

28

23.5

24

24.5

25

25.5

26

26.5

27

27.5

28

28.5

Num

ber o

f Pro

vider

s

Male

Female

n = 53

Provider Demographics: Ethnicity

41

1 2 20

2

0

5

10

15

20

25

30

35

40

45

White Black Asian Hispanic Indian Other

Num

ber o

f Pro

vide

rs

n = 48

Status of Study Subjects

Completers vs. Non-Completers

Completers vs. Non-Completers

39

51

0

10

20

30

40

50

60

Completers Non Completers

Num

ber

of

Pat

ients

n = 90

Non-Completers:

• Patients have or have not completed some portion of the questionnaires. They have NOT completed the S.C.I.D.

• Total: 51/90 = 56%

------------------------------------------------------------------- No Information Collected : 2 * Dem = Demographics

- CAGE Only : 1 **C\J = Compton\Jameson

- Dem*, CAGE : 13

- Dem, CAGE, C\J**: 11

- Dem, CAGE, C\J, I-S.O.A.P. : 2

- Dem, CAGE, C\J, I-S.O.A.P., CMSD : 1

- Dem, CAGE, C\J, I-S.O.A.P., CMSD, PBQ, STAI : 1

- Dem, CAGE, C\J, I-S.O.A.P., CMSD, PBQ, PDQ-4+: 1

- Dem, CAGE, C\J, I-S.O.A.P., CMSD, PBQ, PDQ-4+, BDI-II: 2

- Dem, CAGE, C\J, I-S.O.A.P., CMSD, PBQ, PDQ-4+, CSQ: 1

- Dem, CAGE, C\J, I-S.O.A.P., CMSD, PBQ, PDQ-4+, CSQ, CPSS, SEF, SEOS: 1

- Dem, CAGE, C\J, I-S.O.A.P., CMSD, PBQ, PDQ-4+, CSQ, CPSS, SEF, SEOS, STAI: 8

- Dem, CAGE, C\J, I-S.O.A.P., CMSD, PBQ, PDQ-4+, CSQ, CPSS, SEF, SEOS, STAI, BDI-II: 7

Completers:

Patients have completed all necessary questionnaires AND the S.C.I.D.

Total: 39/90 = 43%---------------------------------------------------------------------------------------

--Dem, CAGE, C\J, I-S.O.A.P.,

CMSD, PBQ, PDQ-4+, CSQ,

CPSS, SEF, SEOS, STAI, BDI-II,

S.C.I.D. : 39

Summary of Recruitment

Successful Strategies and Barriers

Recruitment

• Useful Recruitment Strategies

~ Presence of recruiter in the ED between the hours of 11am-8pm M-F (five day coverage to maximize patient recruitment)

~ Patient completion of BDI-II along with as many questionnaires as possible within the ED

• Barriers to Recruitment

~ 2nd Visit does not receive as much of a response from patients

~ 2nd visit can only be completed on Fridays

~ Excluding patients who arrive by ambulance: Some chronic pain patients, utilize the ambulance to “get a ride” to the ED.

~ 14 day interval between visits is too small

Quantitative Study of Barriers

• Questionnaire for Patients & Providers» Same questions

~ Framed differently

Lack of Time

• Patient• I do not have

adequate time to assess and treat ED patients complaining of chronic pain

• Provider• Doctors and

nurses avoid spending enough time to talk about your chronic pain

Strongly disagreement

Moderate disagreement

Some disagreement

Some agreement

Moderate agreement

Strong agreement

Dunnett t-test post-hocns patient vs physician .113sig patient vs nurse .003

lack of time n=37 n=54 n=19nurse patient physician

0

1

2

3

4

5

Prioritization

• Provider• The treatment of

chronic pain in the ED takes a back seat to treatment of more pressing issues like trauma or myocardial infarctions

• Patient• Doctors and

nurses have more pressing issues than chronic pain (like seeing injured people or those with heart attacks)



Some disagreement

Some agreement

Moderate agreement

Strong agreement

Dunnett t-test post-hocns patient vs physician .184ns patient vs nurse .075

more pressing issues n=37 n=54 n=19

nurse patient physician

0

1

2

3

4

5

Fatalism

• Provider• Chronic pain has

little chance of improving

• Patient• Chronic pain has

little chance of improving



Some disagreement

Some agreement

Moderate agreement

Strong agreement

Dunnett t-test post-hocsig patient vs physician .001sig patient vs nurse <.001

Little Chance of Improving

n=37 n=54 n=19patient physician nurse

0

1

2

3

4

5

Belief in Pathology

• Provider• I do not believe

the validity of a pain complaint in the absence of physical findings or a lack of objective findings on imaging studies, EMG, etc

• Patient• When the doctor

cannot find something wrong on exam or by an X-ray, they tend not to believe you could be in pain



Some disagreement

Some agreement

Moderate agreement

Strong agreement


patient physician nurse

0

1

2

3

4

5

n=37 n=54 n=19

Belief in Pathology

Fear of Addiction

• Provider• I believe that

chronic pain patients who come to the ED are addicted to their pain medications

• Patient• I think that I am

addicted to pain medications



Some disagreement

Some agreement

Moderate agreement

Strong agreement

Dunnett t-test post-hoc sig patient vs physician .003sig patient vs nurse .001

n=37 n=54 n=19

Fear of Addiction


0

1

2

3

4

5

Fear of Dependence

• Provider I avoid

administering opioids because patients will develop physical dependence and go through withdrawal when they abruptly halt the intake of the medicine

• Patient I avoid taking pain

medications because taking them will lead to withdrawal symptoms if I have to stop them



Some disagreement

Some agreement

Moderate agreement

Strong agreement


n=37 n=54 n=19

Fear of Dependence


0

1

2

3

4

5

“Bad” Patient

• Provider

I find myself labeling chronic pain patients as “bad patients” or “drug seekers”

• Patient I believe that

telling doctors and nurses about my pain leads them to consider me to be a “bad patient” or a “drug seeker”



Some disagreement

Some agreement

Moderate agreement

Strong agreement

Dunnett t-test post-hoc ns patient vs physician .108ns patient vs nurse .313

n=37 n=54 n=19

“Drug Seeker”


0

1

2

3

4

5

Qualitative Research Through Interviews

• Access using conversations and consultations with ED physicians

• Taped and transcribed interviews» Anonymity and

confidentiality maintained

Qualitative Research

• Questions» Most problematic chronic pain patient» Limitations on care» Potential sources of improvement

Qualitative Research

• Responses» “ED not designed to see these patients”» “Appropriate referrals to pain specialists

difficult”» Advised patients “find a primary care

doctor”» Provide short acting opioids

~ 20-30 pills of vicodin, codeine, or oxycodone

Estimated Numbers (in Millions) of Lifetime Nonmedical Use of Selected Pain Relievers among Persons Aged 12 or Older: 2002 http://oas.samhsa.gov/2k4/pain/pain.htm

Estimated Numbers (in Millions) of Lifetime Nonmedical Use of Selected Pain Relievers among Persons Aged 12 or Older: 2002 http://oas.samhsa.gov/2k4/pain/pain.htm

Abusive Behaviors

Estimated Numbers (in Millions) of Persons Aged 12 or Older with Past Year Illicit Drug Dependence or Abuse, by Drug: 2002 http://oas.samhsa.gov/2k4/pain/pain.htm\

Estimated Numbers (in Millions) of Persons Aged 12 or Older with Past Year Illicit Drug Dependence or Abuse, by Drug: 2002 http://oas.samhsa.gov/2k4/pain/pain.htm\

Prescription Drug Abuse in ED

» Modeling using multiple regression~ Dependent variable

• Screener and Opioid Assessment for Patients in Pain (SOAPP)~ Independent variable

• Spielberger State-Trait Anxiety Inventory (STAI)

• Beck Depression Inventory (BDI-II)

• Chronic Pain Self-Efficacy Scale (CPSS)

• Coping Strategies Questionnaire (CSQ)

• Unrestricted grant from Endo Pharmaceuticals Inc.

• Inflexxion, Newton, MA» Concept mapping procedures to obtain input

from a panel of pain and addiction medicine specialists

~ Predict which patients will require more or less monitoring on long-term opioid therapy

http:/www.painedu.org. http:/www.painedu.org.

Screener and Opioid Assessment for Patients in Pain (SOAPP)

~ Prescription Drug Use Questionnaire (PDUQ)

~ Judgement by two out of the three staff member groups (e.g., using a physician, nurse, and/or a receptionist) that the patient had a serious drug problem

~ Urine toxicology screening

Compton PJ, Darakjian J, Miotto K. Screening for addiction in patients with chronic pain and "problematic" substance use: evaluation of a pilot assessment tool. J Pain Symptom Manage 1998;16:355-63.Katz NP, Sherburne S, Beach M, Rose RJ, Vielguth J, Bradley J, et al. Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg 2003;97(4):1097-102, table of contents.

Compton PJ, Darakjian J, Miotto K. Screening for addiction in patients with chronic pain and "problematic" substance use: evaluation of a pilot assessment tool. J Pain Symptom Manage 1998;16:355-63.Katz NP, Sherburne S, Beach M, Rose RJ, Vielguth J, Bradley J, et al. Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg 2003;97(4):1097-102, table of contents.

Screener and Opioid Assessment for Patients in Pain (SOAPP)

Predicting Aberrant Medication-Related Behavior

• A cutoff score of 8 was chosen to produce a sensitive test

• Sensitivity of .90» Correctly classified 90% of

the patients who actually went on to exhibit aberrant behaviors

• Specificity of .69» 31% of the people, who

scored an 8 or higher on the SOAPP, did not go on to show detectable aberrant behavior

5 10 15 20 25 30 35 40 45

SOAPP Version 1.0 Summary Score

0

2

4

6

8

10

12

14

Fre

qu

ency

Mean = 19.06

SD = 8.258

N = 47

• Biased population» Poorly controlled» Prescription drug abuse relatively

common in ED setting~ Short acting opioids~ No opioid contracting~ Multiple prescribers

• Instrument not valid in ED

Unexpected Finding

Abusive Behaviors and Psychological Factors

• Prescription drug abuse will correlate with psychological factors» Previous study in pain clinics not

confirmatory~ “Psychosocial testing on clinic admission failed to predict who

would become an opiate abuser”

Chabal C, Erjavec MK, Jacobson L, Mariano A, Chaney E. Prescription opiate abuse in chronic pain patients: clinical criteria, incidence, and predictors. Clin J Pain 1997;13(2):150-5.

Chabal C, Erjavec MK, Jacobson L, Mariano A, Chaney E. Prescription opiate abuse in chronic pain patients: clinical criteria, incidence, and predictors. Clin J Pain 1997;13(2):150-5.

Correlates

• Self Efficacy for Coping with Symptoms

Screening for Prescription Drug Abuse in ED

3 or 4

simple

questions

Prescription Drug Use Questionnaire

• I believe that I am addicted to pain medicine

• I routinely have to take more medication than my doctor prescribes in order to treat my pain

• I prefer certain pain medications or ways of taking these medications (IV, IM routes over the oral route)

Compton PJ, Darakjian J, Miotto K. Screening for addiction in patients with chronic pain and "problematic" substance use: evaluation of a pilot assessment tool. J Pain Symptom Manage 1998;16:355-63.

Compton PJ, Darakjian J, Miotto K. Screening for addiction in patients with chronic pain and "problematic" substance use: evaluation of a pilot assessment tool. J Pain Symptom Manage 1998;16:355-63.

n = 47 Spearman rhor = 0.223p = 0.1312-tailed

10 20 30 40

iSOAPP Score

0

0.5

1

1.5

2

2.5

3C

OM

PT

ON

SC

OR

E (

SU

M O

F P

OS

ITIV

ES

)

CAGE• Have you ever felt the need to Cut down on your

use of prescription drugs?

• Have you ever felt Annoyed by remarks your friends or loved ones made about your use of prescription drugs?

• Have you ever felt Guilty or remorseful about your use of prescription drugs?

• Have you Ever used prescription drugs as a way to "get going" or to "calm down?"

http://www.nida.nih.gov/ResearchReports/Prescription/prescription6.html#Providershttp://www.nida.nih.gov/ResearchReports/Prescription/prescription6.html#Providers

10 20 30 40

iSOAPP Score

0

1

2

3

4C

AG

E S

CO

RE

(S

UM

OF

PO

SIT

IVE

S)


Hx Addiction/Legal Issues• Is there a history of alcohol or substance abuse in

your family, even among your grandparents, aunts, or uncles?

• Have you ever had a problem with drugs or alcohol or attended Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings?

• Have you ever had any legal problems or been charged with driving while intoxicated (DWI) or driving under the influence (DUI)?

Michna E, Ross EL, Hynes WL, Nedeljkovic SS, Soumekh S, Janfaza D, et al. Predicting aberrant drug behavior in patients treated for chronic pain: importance of abuse history. J Pain Symptom Manage 2004;28(3):250-8.

Michna E, Ross EL, Hynes WL, Nedeljkovic SS, Soumekh S, Janfaza D, et al. Predicting aberrant drug behavior in patients treated for chronic pain: importance of abuse history. J Pain Symptom Manage 2004;28(3):250-8.

10 20 30 40

iSOAPP Score

0

0.5

1

1.5

2

2.5

3

JAM

ISO

N S

CO

RE

(S

UM

OF

TH

E P

OS

ITIV

ES

)


Conclusions

• Barriers are present» Similar to other settings

• Chronic pain patients seeking care in ED are special population» Prescription drug abuse

~ More research needed

• Short questionnaire for prescription drug abuse» No definitive answer

Collaborators

• Barth Wilsey MD• Ingela Symreng PhD• Amy Ernst MD• Dan Mungas PhD• Matt Lewis BS, Jeanna Millman BS, &

Christine Ogden BS

Utilization of the Emergency Department by Chronic Pain Patients to Obtain Pain Medications: A Study...

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