Article, Emergency Medicine

Effectiveness of nonnarcotic protocol for the treatment of acute exacerbations of chronic nonmalignant pain

American Journal of Emergency Medicine (2007) 25, 445 – 449

Brief Report

Effectiveness of nonnarcotic protocol for the treatment of acute exacerbations of chronic nonmalignant pain

James E. Svenson MD, MS*, Thomas D. Meyer MD

Section of Emergency Medicine, University of Wisconsin, Madison, WI 53792, USA

Received 7 September 2006; revised 28 September 2006; accepted 29 September 2006

Abstract

Introduction: Emergency department (ED) overcrowding is a growing problem. Frequent visits for chronic pain are a significant subset of patients. The use of narcotics in these patients is controversial. The purpose of this study was to test a strict nonnarcotic protocol in reducing need for and number of ED visits for chronic pain while at the same time addressing their pain.

Methods: This was a prospective observational study. We identified patients with more than 10 ED visits for exacerbations of chronic nonmalignant pain in the last 12 calendar months. Each patient and their physician were sent letters informing them of the concern of frequent ED use and the use of opioids for Rescue therapy. Furthermore, the patient would receive medications other than narcotics in Subsequent ED visits, and follow-up with the primary physician for alternatives was encouraged. Use of the ED for pain-related visits was then monitored for the subsequent 12-month period. Clinic use and outpatient medication uses were also monitored.

Results: Fifteen patients were identified for the initial study. These patients averaged 19 ED visits per 12 months for pain-related complaints. All of them had a regular physician. After notification of the new protocol, ED visits decreased to an average of 2 visits per year. Visits with primary care physicians also dropped from an average of 19 visits per year to 7 visits. There were 7 patients who had been weaned off narcotic medications, 4 who had been converted to methadone maintenance, and 1 who had been switched to a fentanyl patch.

Conclusions: Initiation of a strict nonnarcotic protocol for treatment of patients with frequent ED visits for chronic nonmalignant pain results in a significant drop in the number of pain-related visits to the ED. These visits were not offset by a significant elevation in the number of clinic visits for pain complaints, and many were weaned off narcotics. Nonnarcotic protocols for acute exacerbations of chronic nonmalignant pain may be a viable alternative for reducing frequent pain-related ED visits in a select population.

D 2007

Introduction

Emergency department (ED) overcrowding is a national problem. One contributor is a small group of patients who

Presented at the 2006 SAEM Annual Meeting, San Francisco, Calif.

* Corresponding author. Tel.: +1 608 265 5808; fax: +1 608 262 2641.

E-mail address: [email protected] (J.E. Svenson).

account for a disproportionate number of ED visits [1-3]. Prior studies have reported that 3% to 4% of patients may account for 12% to 20% of total ED visits [1,2]. One subgroup of these consists of patients with chronic, frequent migraines and chronic nonmalignant pain [4,5]. These patients account for about 7% of those frequent users of the ED. This subgroup of Frequent ED users represents a challenging area of patient management.

0735-6757/$ – see front matter D 2007 doi:10.1016/j.ajem.2006.09.018

Programs have been instituted to improve the care and management of frequent ED users in the hopes of decreasing their use. These include, for example, intensive Case management [6], keeping lists of narcotics abusers [7], and limiting the number of providers and pharmacies the patient may use [8]. These approaches may have limited usefulness in the subset of patients with chronic migraines or chronic malignant pain. Limiting the number of ED visits for treatment of acute exacerbations of pain has been one strategy, but again, has not been completely effective [9].

The optimal management of acute exacerbations of chronic pain is controversial, both to avoid the use of potentially inappropriate opioids and at the same time avoid inadequately addressing the patient’s pain. Often, patients with chronic pain treated with chronic opioids can produce a condition of enhanced pain sensitivity [10,11]. As medica- tion wears off, they feel worse. In these cases, short-term parenteral narcotics may be worsening the problem. The American Academy of Pain Management contains several essential recommendations on chronic pain management:

(1) treatment should be provided solely by a single practitioner or clinic; (2) Narcotic use should be limited to circumstances where it enhances function at work and home; (3) escalation of use or seeking narcotics from multiple providers should be considered an indication that narcotic treatment needs to be reviewed and possibly discontinued. Thus, for the chronic pain patient with a personal physician, the current pattern of providing addi- tional narcotics in the ED is contrary to the recommenda- tions of the American Academy of Pain Management. In addition, most opioids used in the ED can be given in alternative forms as an outpatient medication [12]. Some of these may be more appropriate as they have slower onset compared with the rapid onset action of parenteral narcotics [13]. Although narcotics may be suboptimal therapy for acute exacerbations of chronic pain, other Alternative therapies must be offered to each patient to help alleviate their pain.

The purpose of this study was to test a strict nonnarcotic protocol in reducing frequent ED visits for patients with chronic nonmalignant pain while at the same time address- ing their pain.

Methods

This was a prospective observational study. We identified all patients with greater than 10 ED visits to the XXXX ED in the last 12 calendar months. The XXXX ED is a community teaching hospital in a small city environment. Because this was a new protocol, we tried to make the criteria for entry as strict as possible. As a feasibility study, no formal Power calculation was made. The records of these patients were reviewed, and if it was determined that they were treated at these visits for an exacerbation of chronic nonmalignant pain or headache, then they were eligible for

inclusion in this study. Patients were excluded if they did not have more than 10 pain-related visits in the 12-month period, if their pain was not treated with narcotics, if their pain was malignancy-related, or if they had significant underlying medical comorbidities. Comorbidities included renal failure, sickle cell, and so on. Both study coordinators agreed on all exclusions. A letter was sent to each patient by certified mail, which discussed the use of narcotics as rescue therapy for such syndromes. The observation was made that the patient’s physician could supply rescue therapies provided in the ED in alternative outpatient forms and the problems associated with frequent use of narcotics. We then informed the patient that we would no longer treat them with parenteral narcotics in the ED and encouraged to be seen by their personal physician in the near future to discuss alternative therapeutic options. A similar letter was sent to their personal physician (Appendices A and B). We continued to offer nonnarcotic alternatives to treat their exacerbations if they required ED evaluation. We allowed patients a 1-month period to make contact with their physicians to discuss and initiate alternative treatment regimens. When presenting to the ED after this period, alternative nonnarcotic pain management regimens were offered to the patient. alternative regimens offered were at the discretion of the treating ED physician.

Patient use of the ED over the next 12 months (excluding the 1-month period after the letter was sent out in which the patient was to meet with their own physician) was then monitored by review of clinic and ED notes in the patient’s electronic record.

Results

There were 32 patients who had greater than 10 visits per year for acute exacerbations of chronic pain. Of these, 17 were excluded: 8 did not receive narcotics at each visit, 4 had Sickle cell disease, and 4 had complex medical problems or malignancy-related pain. Thus, there were 15 patients included in this preliminary study. One patient was lost during the follow-up periods. Of the remaining, during the 12-month period before entry, these patients had an average of 19 visits per 12-month period for pain-related complaints at which they were treated with narcotic pain medications (range, 14-28).

In the 12-month period after institution of this protocol, ED use fell for each patient. The average number of visits for pain-related complaints fell to 2 per patient per 12-month period (range, 0-8). No violations of the new protocol were recorded. Patients reported pain relief with the new protocols. Every patient reported a pain level of 10/10 on arrival to the ED. After institution of our new protocol, all reported pain relief, but at varying levels (average, 5/10; range, 2-8/10).

Corresponding clinic visits also significantly dropped from an average of 19 visits to 7 visits per 12-month period. During the follow-up period, 7 patients had been weaned off

of narcotic medications, 4 had been switched to methadone maintenance therapy, and 1 converted to a fentanyl patch.

The Total cost before the institution of this policy, including physician, pharmacy and hospital bills, averaged

$800 per patient. The average length of stay calculated from triage to discharge was slightly more than 3 hours. Thus, in the first year after initiation of this protocol, there was a reduction of approximately 255 visits in the ED for chronic pain, with a calculated cost saving of more than $200,000 and the reduction of approximately 765 patient hours. There were no patient complaints or board action brought in relation to the new policy.

Discussion

In this preliminary study, we have shown that the use of a strict nonnarcotic protocol can significantly reduce ED use in those patients presenting with chronic nonmalignant pain. Treatment of bfrequent migraineursQ or those with chronic nonmalignant pain is controversial [14-16]. Although opioids have been used frequently in such patients, these drugs are associated with the potential for abuse, addiction, and tolerance. There is evidence that opioids may be ineffective in neuropathic and idiopathic pain [17]. In addition, treatment with opiates frequently contributes to the psychological aspects of the disease. Many patients use opioids on a daily basis [18]. Chronic use and the use of opioids for acute exacerbations of pain can be associated with a rebound phenomenon, limiting their effectiveness both in the short and long term [19].

Regardless of the appropriateness of narcotics for rescue therapy for patients with acute exacerbation of chronic nonmalignant pain, many narcotics are available in alternative formulations and can be used effectively at home for rescue therapy. For example, effective narcotics are available for rectal, oral (transmucosal), or nasal or even home intramus- cular administration [20-22]. Oral protocols have been used successfully for treatment of acute exacerbations of chronic migraines even if there is associated nausea and vomiting [12]. Limits on the number of acute visits for rescue therapy have been tried but still result in frequent ED visits [9]. Proposals have been made to try to shift treatment of exacerbations of chronic nonmalignant pain to home or family physician’s offices, but these have not been really met with great success [23]. If the outpatient treatment protocol is effective, then these strategies could lead to decreased use [12]. The effective rescue therapeutic regimen could be based on the medications used in repeated ED

visits given in an alternative outpatient form.

Many alternative nonnarcotic regimens for the treatment of acute exacerbations of headache or nonmalignant pain have been studied, with variable results [24-26]. However, there are alternatives that have been shown to be effective, including ketamine [27], droperidol [28] and other neuro- leptics [29], continuous dihydroergotamine (DHE) [30], and

benzodiazepines [10] among others. Thus, in all of our patients with chronic nonmalignant pain, treatment with the use of alternative nonnarcotic regimens were open for the ED physician to use during repeat visits in the time after the institution of our policy.

If narcotic treatment is withheld in the ED setting, patients may seek this treatment in other urgent care or clinic settings. The institution of our protocol did not result in a corresponding increase in outpatient clinic use, but we have no data on the use of urgent care centers or other EDs in the area. However, we noted that clinic use actually declined during the follow-up period, and many patients were successfully weaned from their chronic narcotic medications. The Joint Commission on Accreditation of Healthcare organizations (JACHO) recently published standards that called for the evaluation, treatment, and assessment of effectiveness of pain improvement [31]. In addition, there have been reports of inadequately treated pain in the ED [32]. Given these guidelines and findings, the question is whether the ED physician is compelled both ethically and legally to provide narcotics for pain relief to those with chronic nonmalignant pain. The standards state, bpatients have the right to appropriate assessment and management of pain.Q There are no specific references to opioids, and the necessary degree of relief is not specified [33]. The intent of the standards is that a patient’s pain should be treated in the best way possible. This may exclude narcotics for many

patients with chronic pain.

Many patients with chronic pain actually have improve- ment in their pain when weaned off opioids [34,35]. Some patients’ pain resolves completely with stopping narcotics [36]. In this study, we noted that many patients had actually been weaned from their chronic narcotics after we instituted our new policy apparently without increasing their pain.

If narcotics are used for relief of chronic nonmalignant pain, the medication should be slow-onset. Rapid-onset medication should be avoided because it may cause problem with reinforcing pain behavior and gives a short-lived psychological relief [13]. We noted to each of our patients that alternative, more appropriate rescue therapies than parenteral narcotics in the ED could be worked out with their treating physician and gave them ample time to seek out such regimen. We also notified the patient’s physician of our concerns and change in policy, thus again, encouraging the formulation of a better rescue regimen. We noted that to avoid these reinforcement issues, the patient’s physician has to more appropriately address Rescue medications and regimens. Most pain specialists agree that to maintain control and optimize the patient’s drug usage, only one physician should prescribe opioids [37]. We felt that our protocol encouraged the reinforcement of this behavior by referring the patient back to their own physician for discussion of more

appropriate rescue regimens.

We felt that our protocol, although seemingly draconian, was ethically and medically in the patient’s best interest in treating their chronic nonmalignant pain in the optimal

manner. With this change in policy, our patients experienced improvement in their clinic and ED use and their use of narcotics in controlling their pain.

Conclusions

Initiation of a strict nonnarcotic protocol for treatment of patients with frequent ED visits for chronic nonmalignant pain results in a significant drop in the number of pain-related visits to the ED. These visits were not offset by a significant elevation in the number of clinic visits for pain complaints. Nonnarcotic protocols for acute exacerbations of chronic nonmalignant pain may be a viable alternative for reducing frequent pain-related ED visits in a select population.

Appendix A

Dear Patient:

As a patient who has come to the XXXX ED many times during the last year to receive treatment for pain, we are writing to inform you of a new guideline being used at the XXXX ED for those who suffer from intermittent worsening of chronic pain.

While an important role for physicians is to relieve pain and suffering, we also want to do no harm. Pain relief from injectable narcotics lasts only a short time, while the frequency of rebound pain increases. The medical literature suggests that treatment with short-term narcotics can actually increase the stress and disability associated with chronic pain. In addition, long waits in the ED are common and the noise and chaos of the ED may actually worsen the pain.

We have spoken with primary care and pain physicians in our area about developing a more consistent, coordinated approach to managing those people with chronic pain. From these conversations, our observations, and the medical literature, we have concluded that frequent, short-term narcotic pain treatment is not a healthy approach to pain management. The best results are seen when a patient’s pain is managed through a Primary care physician . The management may include prevention as well as specific pain treatments to be used at home. The PCP may also elect to consult with an area pain specialist who can assist in developing a pain management plan.

Given the above considerations, XXXX emergency physicians can no longer support the use of injectable narcotics for the treatment of intermittent worsening of chronic pain. We realize that it will take some time for you to set up an alternative treatment plan with your PCP. To help you begin this process, we will be contacting your primary care physician with this information. In the interim, we will continue to provide you with your usual care for up to thirty (30) days from the date of this letter.

We hope that this information has been informative and that it will help you know what to expect when you come to

the XXXX ED for medical care. If you need help finding a primary care physician within the XXXX Health system, please contact our Patient Relations Department at XXXXX or you can discuss this with a social worker in the ED.

As always, you are welcome to come to the ED for evaluation of any condition, as well as to receive nonnarcotic treatment for intermittent worsening of your chronic pain.

Sincerely,

Cc: Patient’s PCP & Pain Specialist

Appendix B

Dear Doctor:

We are writing about our mutual patient . As you know he/she frequently uses the ED for acute exacerbations of chronic pain. He/she has been in the ED over 10 times in the last 12 months. During these visits he/she has requested and received rescue therapy including IM/IV narcotics. We would note that this medication is available in equivalent doses in oral, intranasal, or rectal forms.

Current literature would suggest that treatment of acute exacerbations of chronic pain conditions, for example, headache, with narcotics is not optimal. Pain relief from IV or IM narcotics lasts only a Short period of time, while the frequency of rebound pain increases. The literature also reports that short-term narcotic treatment can actually increase the stress and disability associated with chronic pain. Because of this, we do not feel that we can continue to offer narcotics for rescue therapy to patients with acute exacerbations of chronic non-malignant pain. If you feel that narcotics are absolutely necessary for the treatment of this patient’s pain, we would suggest that you work out a plan for rescue therapy using the alternative form mentioned above, in an alternative venue, or that you primarily provide

this therapy in the ED.

Since it takes time to arrange for alternative strategies, we will continue to treat acute exacerbations of your patient’s chronic pain with narcotic rescue therapy for up to 30 days from the time of this letter, though we now feel that therapy is suboptimal. We would expect that within that time frame, you could see your patient and formulate an alternative treatment protocol.

If you have any questions regarding our new policy please do not hesitate to contact us.

Sincerely,

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