Real Pain Protocols

A case study from the Christiana Care Health System in Wilmington, Del.  

Patients who frequent the ED with recurring pain complaints represent a difficult population for the emergency physician to manage. Often times these patients suffer with serious medical ailments and are at risk for being under-triaged or misdiagnosed secondary to staff complacency created by their recidivism. These patients frequently suffer from a lack of social support, are sometimes abandoned by outpatient physicians, and grow to rely on an overburdened and expensive acute care setting for management of chronic ailments.

In the process, many of these patients become dependent upon prescription pain medications, spending hundreds of ED and inpatient days managing recurrent complaints with the expectation that they will receive IV or IM narcotic pain medicines. When visits become frequent, these expectations can lead to friction between the treating EP and patient. This further degrades the environment of care for all ED patients by reducing available resources and negatively impacts staff morale.


Further, variability in the way ED staff approach these patients can contribute to this discord. Some EPs would acknowledge they give IV or IM analgesia to these patients because that is what is expected, not because they feel it is in the best interest of the patient, while others may take a stand and set treatment parameters for these patients – a process that can be both stressful and time-consuming. In short, there is no “easy” way to manage these patients.

One approach to treating these patients was recently implemented at Christiana Care Health System, where a pain management protocol was created for 14 patients, who based upon a data query, used the ED most often over the past year for complaints of recurrent pain. These patients were placed on an “exceptional patient” list that our department uses to identify patients with special medical devices or conditions requiring protocolized care, history of violence, or exceptional pain control needs.

In the case of our pain protocol patients, this program was adopted for several reasons: 1. Inability to change patient usage pattern despite extensive staff efforts with several patients accumulating over 100 ED visits over the past year, 2. Staff frustration over variability in management, 3. Concerns of “drug seeking” behavior displayed by many of these patients, and 4. Concern that patients were being labeled and at risk for medical error should they continue their exceptional usage of the ED.


Given the degree of risk associated with these patients (two of our top 20 most frequent visitors died prior to process implementation) the protocol emphasizes that the treating physician can order any tests when evaluating these patients, and if complaint warrants, discretion allows for patients to fall outside of protocol use. However, the protocol stresses no more than once weekly use, no “to go” medications or prescriptions, dictates that only oral medications are used for the management of chronic pain, and requires a 90-minute wait between oral doses of medications, bucking the trend to meet patient expectations of frequent IV or IM medications. Once enrolled, patients were also provided via mail and during follow-up visits a list of pain management clinics, drug treatment centers and social worker contact information.

To date, we have seen a dramatic decrease in the number of ED and inpatient days from the patients in this program. No known patient complications have occurred. No patients utilized social worker services and no complaints were filed with our department or patient relations. There has been less staff variability in treating these patients and anecdotally, the interactions between staff and super-users have improved.

Dr. Passarello is the Medical Student Clerkship Director at Christiana Care Health System. Dr. Breyer is an Associate Program Director at the Christiana Care Health System Emergency Medicine Residency Program. You may contact him at



  1. My institution has implemented a similar protocol with similar good results. However, the number of pharmacy burglaries for narcotics has increased in my area….

  2. Donald Linder, DO on

    My department has really seen a rise in repeat patients visits for pain medications. Some of us put our foot down as they are obviously drug seeking but some of my partners cave in. Many of us fear the ramifications for upsetting the “clients” as the hospital calls them. Hopefully we can develop some type of pain protocol to.

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