The Golden Rule for Pain

The key to pain management is to treat your patient the way you’d want to be  treated. But are EPs a part of the pain care solution or the problem?

As the number of chronic pain patients presenting to our EDs increases, so does the intolerance of their presence. In fact, there is no other subset of patients against which EPs have banned together, denouncing the legitimacy of their visits and symptoms, suggesting they’re not worthy of our time, energy or talents. So, where is the coalition against drunk spitters who slur profanity at us?  I guess those loogie-hocking drunks don’t push our buttons like chronic pain patients do. 

Despite the efforts of many, these patients just aren’t going away. Should they? I personally don’t mind caring for these patients. Their needs are usually well defined. They don’t require testing, and they have clear expectations. I’ll trade my spitting drunk for your chronic pain patient any day.


The prejudice born against those with chronic pain has been cloaked in defenses such as aiding the DEA. But these excuses are a means to justify imposing your biases on your patients. We don’t start tracking down speeders on the highway to reduce traffic fatalities, so why do we feel compelled to become DEA deputies? The “DEA” issues gave legs and legitimacy to the biases. Without that legitimacy, how could anyone feel right about treating these patients differently than the rest? Unfortunately, the pathology has finally caught up with the concerns. Addiction is a real issue in this country. However, the ED isn’t responsible for it.

Is oligoanalgesia still an issue? Yes. Patrick Wall, in Pain: The Science of Suffering, wrote, “It is of course, a complete myth that a standard cause produces a standard pain.” Pain is a subjective business, managed on a case-by-case basis with no objective means of measurement. Despite the light on this subject, the trend for oligoanalgesia continues. It’s time to address the barriers.

There is substantial variation of pain management in emergency medicine. Rupp, et al., in the Annals of Emergency Medicine (2004), reported several factors resulting in the inconsistency and inadequacy of ED pain management. Some of the factors noted were “the clinician’s attitudes toward opioids, resulting in inappropriate diagnosis of drug-seeking behavior, inappropriate concerns about the safety of opioids and bias and disbelief of pain-reporting according to racial and ethnic stereotyping.” A review of 1,360 patients confirmed wide variations in adequacy of pain management in the ED. ED pain management was inadequate with comparison to the goals of the WHO, AMA and ACEP (J Opioid Management. 2006 Nov-Dec;2(6):335-40).


Is race really a barrier? Every time this concept is shuffled, and re-dealt, the answer is, “Yes.” In Academic Emergency Medicine, February 2006, the physician’s perception of exaggerated symptoms was associated with the patient’s ethnicity, and this perception resulted in a negative impact on the patient’s pain relief. Despite an increase in ED opioid prescribing from 23% to 37% between 1993 and 2005, the differential prescribing between caucasians and other ethnic groups did not change, 40% vs. 32%.

Recognizing barriers helps to overcome them. Concern about abuse and addiction is a real barrier. Americans comprise 4.6% of the world’s population. However, we consume 80% of the world’s opioid supply and 99% of the hydrocodone supply. Houston, do we have a problem? Sure we do! 80% of American high school and 44% of middle school students have witnessed illegal drug use at their schools. Another fun fact is that 20% of the population has reported recreationally using psychotherapeutic drugs at some point in their lifetime (Pain Physician. 2008 Mar; 11: S63-88).

Where there’s abuse, there’s addiction. There are two primary drivers for addiction: a previous history of ethanol/illicit substance abuse or addiction and a history of mental illness. Non-opioid substance abuse is the strongest predictor of addiction (odds ratio: 2.34), with a history of mental health disorders moderately predictive (odds ratio: 1.46). (Pain. 2007 Jun;129(3):355-62; Pain Med. 2008 May-Jun;9(4):444-59.)

Where there’s addiction, there’s death. In JAMA, Dec 2008, Hall studied 295 unintentional overdose fatalities. Certain behaviors were associated with a higher likelihood of overdose. Diversion was discovered in 63% of fatal OD victims. 21% had been doctor shopping, as evidenced by multiple prescriptions from multiple providers. Diversion was more likely between 18 and 24 years, with doctor shopping more common in women, 31%. Multiple contributory substances were discovered in 79%, and opioid analgesics taken by 93%. Interestingly, opioids had only been prescribed to 44%.


Although the impact of addiction may be catastrophic, the actual rate of addiction is relatively low, 3.27% in chronic pain patients. If the patients were screened for no previous abuse or addiction, the rate dropped to 0.19%. (Pain Med. 2008 May-Jun:9(4):444-59.)  

Despite the sobering data on addiction, we shouldn’t be afraid to prescribe narcotics in the absence of these risk factors. When there is concern for potential addiction, narcotics aren’t the right answer. This is often where the communication stops and the argument begins. Arguing with patients implies you’re not in charge. You’re always in charge. Thus, there is never a reason to argue about your treatment plan. Saying “no” is a reasonable option. Just try not to follow it with, “You drug-seeking %*%$!”

Pseudoaddiction is a real phenomenon resulting from inadequate pain management that may fool even the most astute clinician. I suspect a very large percentage of our patients are in this category. They begin to develop aberrant drug-related behaviors, such as drug hording, requesting specific drugs, unapproved dosage escalations and frequenting EDs. The classic distinction is that once their pain is managed effectively, these behaviors resolve. So, whether you’re dealing with addiction or pseudoaddiction, you’ve got to remember that you’re dealing with a mental health issue. Although they may not be suicidal or psychotic, many chronic pain patients have a component of mental illness. So, treat the pathology with referral for detox, counseling or emergent mental health evaluation if indicated.

Is it so surprising that these patients end up in our EDs? Patients with many different complaints come to the ED, because they have nowhere else to go. Inadequate pain management from other providers drives them to us. Providing episodic pain care is one thing. But regular, routine chronic pain management in the ED is something else and often a pressure point for us and the staff. Protocols for those who frequent the ED are becoming popular. They are complex and challenging to implement. However, they can be very effective. Svenson reported a decrease in ED and primary care visits for patients enrolled in their program over a 12-month period. Frequent ED users and their primary care physicians were sent letters outlining the concerns of frequent ED use and opiate rescue. Non-narcotics were utilized in subsequent visits, and primary care follow up for alternatives was encouraged (Am J Emerg Med 2007 May). 


turning gray areas into black and white
eight essential pearls for proper pain management

(1) Narcotics are safe in reasonable doses for short periods of time.

(2) When in doubt, treat the pain. Withholding analgesia from even one patient with legitimate pain is a tragedy.

(3) Leave your baggage at the door. Treat them any way you feel appropriate, but treat them. Abandoning them because of a judgment fueled by bias is just plain wrong.

(4) Screen for mental illness and previous or current addiction. If you find it, treat it.

(5) Abuse/addiction and mental health disorders are risk factors for addiction and unintentional overdose. This is your “out” if you don’t want to prescribe narcotics.

(6) Use non-narcotic analgesics as adjuncts to reduce narcotic needs or as an alternative altogether.

(7) Refer these patients to pain management or primary care. If you call and make the appointment, there are no excuses for not showing up.

(8) Consider a pain management protocol for patients with frequent visits. Remember, this is a system to help them, not you. Setting up a file of “frequent flyers” with no plan to help them only serves as a “black list” for the ED.

Kevin M. Klauer, DO is the Director of the Center for Emergency Medical Education (CEME)


  1. George Hansen, MD on

    Treating chronic pain patients in the ER is far more complicated than just the problems of addiction and abuse. While these issues are serious, they affect a minority of pain patients. However, tolerance and Opioid-Induced Hyperalgesia (OIH) affect the majority, if not all persons chronically taking opioid analgesics at high doses.(1) Remember, opioids function by activating the endogenous opioid response integral to a patient’s normal pain modulation. Creating tolerance to exogenous opioids cannot help but mess up this system. For example, it has been shown that giving surgical patient high doses of opioids in the OR results in increased opioid consumption post op. In the population of patients who have already demonstrated analgesic tolerance and dose escalation, i.e., those we see in the ER, you can expect that the shot you give will leave them worse off thereafter.

    This problem is further compounded by the reward of dysfunctional behavior. Only a small minority of chronic pain patients regularly come into the ER demanding high doses of parenteral narcotics. The majority of chronic pain patients follow the advice of their pain specialists, which generally involves multidisciplinary therapy and controlled opioid administration. We violate these principals of treatment virtually every time we give a chronic pain patient a shot. Furthermore, it has been demonstrated that catastrophizing and exaggerated pain behavior actually make pain worse. Reinforcing such behavior is hurting the patient. Again, we are causing these patients more pain in the long run.

    Giving chronic pain patients a shot every once in a while probably won’t cause too much damage. The emergency departments in our area have agreed to generally limit injections to two per month, and we have achieved consensus with the community physicians and pain specialists. Even our most generous ED physicians abide by this. Patients reluctantly comply. When they come in the third time, they may be given an oral dose of something strong (preferably long-acting like MS Contin), although some patients prefer the placebo effect of a Toradol shot.

    Two injections a month may seem like a lot, and it is probably more than optimum, but it is a workable compromise that likely has minimal detriment for the patient. Moreover, the limitation eliminates the fight between staff and the “frequent flyers” (thus reducing the need for exaggerated pain behavior). It also forces chronic pain patients to be judicious in choosing when they come in for a shot, which itself has therapeutic benefit.

    (1) Angst, MS and Clark JD. Opioid-induced hyperalgesia. A qualitative systematic review. anesthesiology 2006;104:570-87.

  2. Although I have been in therapy for 24 years now I am on the proper treatment with medications. So, I am quite stable. The problem is that once a doctor in pittsburgh pa. finds this out they are reluctant to give me opoid therapy. Yes, this leads me back to the ER and back to start with a new primary care physician and yes they are bias and I am afraid to transfer my records due to the bias behavior I am confronted with. I will be treated with opoids and then just like that shut off for what ever bias reason they think up, or because I myself am a liability to the practice. I hate this, any suggestions.

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