Sergey Motov on how national medical society interest groups are forging meaningful pain care guidelines. Interview by Nicholas Genes, MD, PhD.
NICK GENES: Congratulations on setting up your Pain Group in AAEM. We noticed ACEP has now formed a Pain Section, with an ambitious agenda. EPs are caught in a tough spot when trying to treat a patient’s pain – worrying about causing a bad outcome, but also worried about their own patient satisfaction scores or angry letters to administrators. Is that what’s motivating these new groups within our professional societies?
SERGEY MOTOV: The time for creating pain management interest groups has been long overdue. It is imperative for EM Doctors to have a governing body within the specialty that will guide them towards safe and effective pain management. It can also protect them to do what is right for the patients without being worried about patient satisfaction scores or push from administration to prescribe unnecessary or even harmful analgesics. We need a set of guidelines or set of recommendations that will arm us with an evidence-based approach to perfecting pain management in the ED. I still remember looking for guidance or recommendations on the ACEP, AAEM or SAEM website on various ED pain regimens 10 years ago when I started working as an attending. What’s the right dose of morphine? When should I pick morphine over hydromorphone or should I use fentanyl? Should I use an opioid at all? Do I have alternatives to opioids? There was nothing back then – no groups, no statements, no guidance.
GENES: Yeah, I remember reading Ben Friedman’s papers on ED pain management back then – they were looking back at Goodman & Gilman equivalencies between various opioids, looking at effective dosing.
MOTOV: Right! A lot of research has come out in the past ten years that improved and enriched our understanding of the neurobiology of pain. Most importantly, evidence has demonstrated that opioids are not the panacea for everything. We EM docs did not have this knowledge 20 years ago and, unfortunately, we were misled and misinformed about the safety of opioid analgesics. In late nineties and early 2000s there was a real push for opioid use in the ED to combat a problem of oligoanalgesia stemmed from earlier research in pain literature. In addition, there was a pharma-sponsored (Purdue) push to see opioid prescribing as being safe, effective and non-addictive. This was heavily supported by the American Pain Society, the Federation of State Medical Boards and the Joint Commission. In addition, there was a pharma-sponsored (Purdue) push to see opioid prescribing as safe, effective and non-addictive. This was heavily supported by the Federation of State Medical Boards and Joint Commission. That “war on oligoanalgesia” has led to a public health tragedy known now as an opioid epidemic. The very same doctors who were at the front lines in promoting uncontrollable opioid use are now apologizing for misleading physicians and the public.
GENES: At least now we do have some guidance.
MOTOV: About 5 years ago ACEP and AAEM (independently) issued guidelines on ED management for chronic non-cancer pain with a concise and direct message of avoiding opioids for this type of pain. According to the guidelines, if opioids are prescribed, only an immediate-release formulary for a very short course (3-5 days) with the smallest effective initial dosing should be used. That was a great beginning and great step to empower ED Doctors to use opioids judiciously.However, we still did not have an EM pain management task force or committee that would have taken the initiative of evidence–based approach to ED pain management further. Now we need a body within the specialty that will accomplish two things: First, a creation of guidelines of acute pain management in the ED that will arm ED physicians with large armentarium of analgesics (opioid and non-opioid) and a solid evidence-based approach on their use for a variety of pain syndromes.. Second, an empowerment of ED Doctors to use these therapies safely and effectively without being afraid of being reprimanded or financially punished by their administration. We need a clear, concise, and bias-free set of recommendations backed by ACEP, AAEM, and SAEM to allow EPs to manage pain safely and effectively.
GENES: You don’t need a section like this, though. You’re on top of the literature, and even conducting your own pain studies.
MOTOV: We do have a group of EPs who are extremely passionate about safe, effective and even cutting edge pain management strategies in the ED and who have developed a true expertise in the field of ED analgesia. It is a good start but to make a change on a scale of a unified approach to pain in the ED we will need an entire specialty. Pain committees are necessary to create practical guidelines that EPs can utilize in their daily practice. Our colleagues need something that they can lean on, something to back themselves up. When ACEP issues guidelines, they are recognized everywhere. As an example, the Pain and Procedural Sedation Interest Group at AAEM is focusing on three main points. First, a creation of acute pain management guidelines in the ED; second, promoting safe and effective use of opioid analgesics in the ED and the third, a re-enforcement of the need for collaboration among different specialties that involves anesthesia, pain medicine, palliative care, and others.
GENES: Everyone talks about bringing other specialties on board. It sounds nice but can backfire, or slow things down.
MOTOV: It’s imperative for successful pain management within the institution. Here is an example: I use low-dose ketamine as a short-term infusion and continuous infusion in the ED daily. Once I had a patient with severe neuropathic pain due to lumbar radiculopathy whose pain was well controlled with the ketamine infusion. The patient had to be admitted to the hospital as pain was still interfering with his ability to ambulate and once on the floor, ketamine was discontinued and pt was switched to hydromorphone. Two issues arose: the analgesic modalities we use in the ED were not allowed on the floor and the admitting team of doctors were unfamiliar with ketamine therapies. We need to be able to bring downstairs care upstairs and as such, we need an entire institution on board.
GENES: Well that’s three reasonable goals for AAEM – but I see the ACEP Pain Section has 8 goals. And it’s a brand new section, just announced! Suboxone use? An ACGME-accredited Pain fellowship? That’s ambitious.
MOTOV: The goals are ambitious but that is very good. We need these ambitious goals to provide our colleagues with a solid evidence –based frame of effective ED analgesia that will educate, support and protect them.
GENES: If you had to focus on one goal, what would it be?
MOTOV: Acute pain management guidelines. Everything else would be wonderful but to me, this is what’s most necessary for the ED. We have a great body of cutting-edge pain research in the ED that needs to be put into the guidelines.
GENES: How could these guidelines be concise? They would be huge – Separate considerations for back pain, headache, trauma, and so on. Peds vs Adults vs Geriatrics. Pregnancy considerations. It would be an entire book!
MOTOV: Not a book. If we use an evidence-based, patient-specific, pain-syndrome targeted approach with opioid and non-opioid analgesics with clear dosing regimens and potential side effects, it may not take more than 5-8 pages. The most important part of these guidelines is to arm ED Doctors with a variety of pharmacologic and non-pharmacological modalities that can be safely utilized in the ED and tailored to individual patients and pain syndromes.
GENES: And when I ask for IV lidocaine for my patient with renal colic, and the staff looks at me like I’m crazy, I can point to this guideline and it’ll be OK?
MOTOV: Yes, even for IV Lidocaine for renal colic as long as this analgesics modality is supported by these guidelines. However, it is extremely important to educate your colleagues and staff members about new analgesic modalities you may be using for pain control in the ED.
GENES: So until then, what is today’s EP supposed do? What’s your recommendation, for each emergency physician to get better at pain management? Is there an article, book, or course you’d recommend? Should they serve on a hospital committee, or join a new pain section?
MOTOV: I would recommend starting by asking yourself whether or not there are other ways (alternatives) to the way I manage pain in the ED. Do the research, find the most cited authors, and review their work and … you may also consider interacting with them through conferences, societal meetings, and even social media. You will gain the necessary knowledge and confidence in order to try these alternatives. When you try something new and see it works, you’ll become a believer – you’ll be sharing your experiences with your colleagues and ultimately, get them onboard. Before you know it, you are a pain expert in your department and then you join the committees. That is how you can make a difference and to contribute to the field of ED analgesia.
GENES: You’re preaching to the choir here with social media.
MOTOV: That is after all how we first met. I am a big proponent of Free Open Access Medical Education, and I strongly recommend its use for EPs. Last thing I want to point out is that ED Doctors must take charge and ownership in managing a variety of acute and chronic painful conditions. We are Emergency Medicine Algiatrists and we need to be proud of providing the best possible pain relief to our patients.