1) Define your goals. What do you hope to accomplish? The development of a more unified approach to chronic pain management, a legal habitual file, ED pain contracts, outpatient referrals to pain clinic or rehab, or the identification of peddlers?
-If you plan to track patients how will this occur?
-Who decides? (Hint: physician group consensus, not an irritated triage nurse.)
-How will they be identified in future visits?
-Who will have access to the information?
Are you going to develop prescribing guidelines?
-Type of medicine- NSAID, opioid, long acting opioid, muscle relaxants, benzodiazepines
-Number prescribed- and will this be modified depending on frequency of visits per month?
-Capsule versus pill- some feel capsules have less street value
-When should PCP be notified?
-When should social services be involved?
3) Get your risk managers involved early. Although nothing in EMTALA states that ED patients have the right to an opioid script, the Board of Medicine has disciplined doctors for the undertreatment of pain. It is important to get your legal department involved so your policy complies with current institutional guidelines and state law. If done hastily, you could be setting your group up for a law suit based on a claim of failure to treat, discrimination or abandonment.
4) Use information technology (I.T.) With more departments using electronic records it is much easier to track prior visits and prescribing habits. Some states now have data banks which can be assessed to determine if the patient is receiving multiple scripts from multiple providers (such as the Kasper program in Kansas.) I.T. can also help you set up habitual files or access pain contracts in confidential, limited access files complying with legal standards.
5) Use support services. Are there legitimate barriers which are preventing the patient from receiving appropriate outpatient services? Social workers and case managers may be extremely helpful in this regard. As chronic pain and depression often go hand in hand, you might also consider setting the patient up with a mental health provider.
6) Reach beyond the ED. If the patient does not have a primary care doctor, is there a clinic they should be referred to? Ideally, this clinic would be one which your ED has already worked with to set up the following:
-I.T. involvement so that the clinic can follow frequency of ED visits and medications prescribed and the ED can follow compliance of outpatient follow up
7) The final straw. For those patients who are non-compliant with outpatient follow up and who are seen for multiple visits requesting an opioid script, it is possible to work with your legal department to send them a letter (with a copy placed in a confidential portion of their medical record/habitual file). This letter should state what treatment plan they should anticipate receiving during their next ED visit. If the patient returns for a non-acute pain issue the letter can be handed to him and the treatment plan enacted. These letters must be very carefully crafted. If the language suggests that the patient should not or may not return to the ED, it may be interpreted as an EMTALA violation.