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Utilization of the Emergency Department by Chronic Pain Patients to Obtain Pain Medications: A Study of Barriers to Treatment, Abusive Behaviors and Psychological Factors

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slide1

Utilization of the Emergency Department by Chronic Pain Patients to Obtain Pain Medications:A Study of Barriers to Treatment, Abusive Behaviors and Psychological Factors

  • Scott M. Fishman, MDChief: Div. of Pain MedicineDept. of Anesthesia & Pain MedicineUC Davis Medical CenterProfessor of AnesthesiologyUniv. of California, DavisSchool of Medicine
background
Background
  • Mayday Foundation RFP
  • ED paper
    • Literature review
      • Chronic pain evaluation
        • LBP
        • Headaches
        • Sickle Cell
        • Ureterolithiasis

Wilsey, Fishman, Rose, Papazian, Pain management in the ED. Am J Emerg Med 2004; 22: 51-7

barriers to treatment
Barriers to Treatment
  • Quantitative data
    • Questionnaires
      • Patients
      • Physicians
      • Nursing staff
  • Qualitative analysis
    • Interviews
      • On perceived barriers to care in the ED from the perspective of physicians
scott fishman md barth wilsey md ingela symreng phd dan mungas phd christine ogden bs

Utilization of the Emergency Department by Chronic Pain Patients to Obtain Pain Medications: A Study of Barriers to Treatment, Abusive Behaviors and Psychological Factors

Scott Fishman, MD, Barth Wilsey, MD,

Ingela Symreng, PhD, Dan Mungas, PhD,

Christine Ogden, BS

overview
Overview
  • Study Structure
  • Method of Recruitment
  • Selected Population

~ Patient Demographics

~ Provider Demographics

  • Status of Recruited Patients
  • Successful and Failed Recruitment Techniques
study structure visit 1
Study StructureVisit 1
  • Subject recruited while they are in the ED to be treated for chronic pain, duration  6 months
    • Fill out as many questionnaires as possible
      • Demographics, CAGE and Compton/Jameson Questionnaires
    • I-S.O.A.P., C.M.S.D., P.B.Q., PDQ-4+, C.S.Q., C.P.S.S., S.E.F., S.E.O.S., STAI, and BDI-II
  • Subject given contact information
    • Advised of a F/U appointment with the psychologist
      • Scheduled within 14 days after the ED visit
study structure visit 2
Study Structure Visit 2
  • Subject contacted within one week of ED Visit to schedule a F/U visit with psychologist
    • If all questionnaires are not complete
      • Opportunity at time of F/U visit to complete all questionnaires
    • The patient will meet with the psychologist for the S.C.I.D.
    • After meeting with the psychologist, the patient is informed about payment for participation
  • Completed Subject
    • A set of complete questionnaires, BDI-II, and S.C.I.D. evaluation
method of recruitment academic offices
Method of Recruitment – Academic Offices
  • Ability to view the ED “Whiteboard” via remote computer in our Academic Offices enables remote screening
    • Research Assistants can utilize computers to look for patients who complain of the following generalized symptoms:

~ Chronic or Mild Stable Pain

~ Chronic Back Pain

~ Headache

~ Earache

~ Rx Refill Request

~ Diffuse Body Pain

~ Vague Abdominal Pain

  • Students travel to the ED to recruit these identified subjects
method of recruitment ed
Method of Recruitment – ED
  • Students within the ED have significant access
    • Electronic “Whiteboard”, patient charts, and physical “Whiteboard”
    • Patients recruited using the inclusion/exclusion criteria designated by the protocol
  • Students approach patients within different Areas, including the waiting room, where they will proceed through the following steps:
    • Brief introduction to the study
    • Informed Consent
    • Administration of Study Questionnaires
    • Collection of all study materials before student and/or patient departs from the ED
continued contact post ed visit

Continued Contact Post ED Visit

A Research Assistant will contact subject via telephone within 1 week of the initial ED visit

At this time, the subject is scheduled to complete Visit 2 within 14 days of the initial ED visit

The subject is contacted by telephone up to three times before the patient will be discontinued due to lack of compliance

subject selection
Inclusion Criteria

Male/Female  18 yrs of age

Patient is being seen at the University of California Davis ED for Schedule II medications

Patient has had pain for 6 months or longer prior to enrollment for which schedule II medications are already being prescribed

Patient presents to the ED with a complaint of vague head, abdomen, or back pain of nonacute onset, diffuse body paint, etc

Patient is able to read, understand, and voluntarily sign the approved informed consent form prior to the performance of any study specific procedures

Exclusion Criteria

Patient arrived by ambulance

Patient has an emergency medical condition

Patient states that they are not comfortable reading and comprehending English

Patient is unwilling or unable to comply with the study visit schedule

Subject Selection
types of employment
Currently Employed : Line of Work

~Building Maintenance

~ Scrub Technician

~ Construction

~ Testing Technician

~ Stock Worker

~ Telemarketer

~ Editor

~ Housekeeper

~ Receptionist

~ Physical Therapist

~ Luggage Handler

~ Drug and Alcohol Counselor

~ Customer Service Clerk

~ Environmental Manager

~ Wildland Firefighter

~ Mental Health Worker

~ Writer

~ Cable

~ Truck Driver

~ Musician

Currently Unemployed: Longest Employment

~Fence Builder ~ Cable

~ Presser/Dry Cleaner ~ Dock worker

~ Retail Management ~ Contractor

~ Engineering Technician ~ Housekeeping

~ Insurance ~ Janitor

~ Figure Skater ~ Painter

~ Analytical Chemistry ~ Roofing

~ Asst. Supervisor for Distrib. ~ Lumberjack

~ Homemaker ~ Homemaker

~ Nursery Employee ~ Truck Driver

~ Underground Construction ~ Cashier

~ Limousine Company ~ Army

~ Restaurant Work ~ Cook

~ Bakery Machine Operator ~ Healthcare Research

~ Fast Food Customer Service ~ Cabinet Worker

~ Warehouse Worker ~ Plumbing/Electrical

~ Operating Engineer Miner ~ Computer Programmer

~ Office Furniture Installer ~ Mechanic

~ Mental Health Case Mgr. ~ Welder/Fabricator

~ Accounting ~ In House Security

~ Sales

Types of Employment
status of study subjects

Status of Study Subjects

Completers vs. Non-Completers

slide25
Non-Completers:
  • Patients have or have not completed some portion of the questionnaires. They have NOT completed the S.C.I.D.
  • Total: 51/90 = 56%

------------------------------------------------------------------

- No Information Collected : 2 * Dem = Demographics

-CAGEOnly : 1 **C\J = Compton\Jameson

-Dem*,CAGE: 13

- Dem,CAGE,C\J**: 11

-Dem,CAGE,C\J, I-S.O.A.P. : 2

-Dem,CAGE, C\J, I-S.O.A.P.,CMSD : 1

-Dem, CAGE, C\J, I-S.O.A.P.,CMSD, PBQ, STAI : 1

-Dem, CAGE,C\J, I-S.O.A.P.,CMSD, PBQ, PDQ-4+:1

-Dem, CAGE, C\J, I-S.O.A.P.,CMSD, PBQ, PDQ-4+,BDI-II: 2

-Dem, CAGE,C\J,I-S.O.A.P.,CMSD, PBQ, PDQ-4+,CSQ: 1

-Dem,CAGE, C\J,I-S.O.A.P.,CMSD, PBQ, PDQ-4+,CSQ, CPSS, SEF, SEOS: 1

- Dem, CAGE, C\J, I-S.O.A.P.,CMSD, PBQ, PDQ-4+,CSQ, CPSS, SEF, SEOS, STAI: 8

- Dem, CAGE, C\J, I-S.O.A.P.,CMSD, PBQ, PDQ-4+,CSQ, CPSS, SEF, SEOS, STAI, BDI-II: 7

slide26

Completers:

Patients have completed all necessary questionnaires AND the S.C.I.D.

Total: 39/90 = 43%

----------------------------------------------------------------------------------------

Dem,CAGE, C\J,I-S.O.A.P.,

CMSD, PBQ, PDQ-4+,CSQ,

CPSS, SEF, SEOS, STAI, BDI-II,

S.C.I.D. : 39

summary of recruitment
Summary of Recruitment

Successful Strategies and Barriers

recruitment
Useful Recruitment Strategies

~Presence of recruiter in the ED between the hours of 11am-8pm M-F (five day coverage to maximize patient recruitment)

~ Patient completion of BDI-II along with as many questionnaires as possible within the ED

Barriers to Recruitment

~2nd Visit does not receive as much of a response from patients

~ 2nd visit can only be completed on Fridays

~ Excluding patients who arrive by ambulance: Some chronic pain patients, utilize the ambulance to “get a ride” to the ED.

~ 14 day interval between visits is too small

Recruitment
quantitative study of barriers
Quantitative Study of Barriers
  • Questionnaire for Patients & Providers
    • Same questions
      • Framed differently
lack of time
Patient

I do not have adequate time to assess and treat ED patients complaining of chronic pain

Provider

Doctors and nurses avoid spending enough time to talk about your chronic pain

Lack of Time
slide31

Strong agreement

5

Moderate agreement

4

]

Some agreement

3

]

]

Some disagreement

2

Moderate disagreement

1

Strongly disagreement

0

nurse

patient

physician

Dunnett t-test post-hoc

ns patient vs physician .113

sig patient vs nurse .003

n=37n=54n=19

lack oftime

prioritization
Provider

The treatment of chronic pain in the ED takes a back seat to treatment of more pressing issues like trauma or myocardial infarctions

Patient

Doctors and nurses have more pressing issues than chronic pain (like seeing injured people or those with heart attacks)

Prioritization
slide33

5

]

]

4

]

3

2

1

0

nurse

patient

physician

Strongagreement

Moderate agreement

Some agreement

Some disagreement

Moderate disagreement

Strongly disagreement

Dunnett t-test post-hoc

ns patient vs physician .184

ns patient vs nurse .075

n=37 n=54 n=19

more pressing issues

fatalism
Provider

Chronic pain has little chance of improving

Patient

Chronic pain has little chance of improving

Fatalism
slide35

Strong agreement

5

Moderate agreement

4

]

Some agreement

3

Some disagreement

2

]

]

Moderate disagreement

1

Strongly disagreement

0

patient

physician

nurse

n=37 n=54 n=19

Dunnett t-test post-hoc

sig patient vs physician .001

sig patient vs nurse <.001

Little Chance of Improving

belief in pathology
Provider

I do not believe the validity of a pain complaint in the absence of physical findings or a lack of objective findings on imaging studies, EMG, etc

Patient

When the doctor cannot find something wrong on exam or by an X-ray, they tend not to believe you could be in pain

Belief in Pathology
slide37

Strong agreement

5

Moderate agreement

4

]

Some agreement

3

Some disagreement

2

Moderate disagreement

]

1

]

Strongly disagreement

0

patient

physician

nurse

n=37 n=54 n=19

Dunnett t-test post-hoc

sig patient vs physician .001

sig patient vs nurse <.001

Belief in Pathology

fear of addiction
Provider

I believe that chronic pain patients who come to the ED are addicted to their pain medications

Patient

I think that I am addicted to pain medications

Fear of Addiction
slide39

Strong agreement

5

Moderate agreement

4

Some agreement

3

]

Some disagreement

2

]

Moderate disagreement

1

]

Strongly disagreement

0

patient

physician

nurse

n=37 n=54 n=19

Dunnett t-test post-hoc

sig patient vs physician .003

sig patient vs nurse .001

Fear of Addiction

fear of dependence
Provider

I avoid administering opioids because patients will develop physical dependence and go through withdrawal when they abruptly halt the intake of the medicine

Patient

I avoid taking pain medications because taking them will lead to withdrawal symptoms if I have to stop them

Fear of Dependence
slide41

Strong agreement

5

Moderate agreement

4

3

Some agreement

2

Some disagreement

]

Moderate disagreement

1

]

]

Strongly disagreement

0

patient

physician

nurse

n=37 n=54 n=19

Dunnett t-test post-hoc

sig patient vs physician .018

sig patient vs nurse <.001

Fear of Dependence

bad patient
Provider

I find myself labeling chronic pain patients as “bad patients” or “drug seekers”

Patient

I believe that telling doctors and nurses about my pain leads them to consider me to be a “bad patient” or a “drug seeker”

“Bad” Patient
slide43

Strong agreement

5

Moderate agreement

4

Some agreement

3

]

Some disagreement

2

]

]

Moderate disagreement

1

Strongly disagreement

0

patient

physician

nurse

n=37 n=54 n=19

Dunnett t-test post-hoc

ns patient vs physician .108

ns patient vs nurse .313

“Drug Seeker”

qualitative research through interviews
Qualitative Research Through Interviews
  • Access using conversations and consultations with ED physicians
  • Taped and transcribed interviews
    • Anonymity and confidentiality maintained
qualitative research
Qualitative Research
  • Questions
    • Most problematic chronic pain patient
    • Limitations on care
    • Potential sources of improvement
qualitative research46
Qualitative Research
  • Responses
    • “ED not designed to see these patients”
    • “Appropriate referrals to pain specialists difficult”
    • Advised patients “find a primary care doctor”
    • Provide short acting opioids
      • 20-30 pills of vicodin, codeine, or oxycodone
slide47

Estimated Numbers (in Millions) of Lifetime Nonmedical Use of Selected Pain Relievers among Persons Aged 12 or Older: 2002 http://oas.samhsa.gov/2k4/pain/pain.htm

slide49

Estimated Numbers (in Millions) of Persons Aged 12 or Older with Past Year Illicit Drug Dependence or Abuse, by Drug: 2002 http://oas.samhsa.gov/2k4/pain/pain.htm\

prescription drug abuse in ed
Prescription Drug Abuse in ED
  • Modeling using multiple regression
    • Dependent variable
      • Screener and Opioid Assessment for Patients in Pain (SOAPP)
    • Independent variable
      • Spielberger State-Trait Anxiety Inventory (STAI)
      • Beck Depression Inventory (BDI-II)
      • Chronic Pain Self-Efficacy Scale (CPSS)
      • Coping Strategies Questionnaire (CSQ)
slide51

Screener and Opioid Assessment for Patients in Pain (SOAPP)

  • Unrestricted grant from Endo Pharmaceuticals Inc.
  • Inflexxion, Newton, MA
    • Concept mapping procedures to obtain input from a panel of pain and addiction medicine specialists
      • Predict which patients will require more or less monitoring on long-term opioid therapy
  • http:/www.painedu.org.
slide52

Screener and Opioid Assessment for Patients in Pain (SOAPP)

  • Prescription Drug Use Questionnaire (PDUQ)
  • Judgement by two out of the three staff member groups (e.g., using a physician, nurse, and/or a receptionist) that the patient had a serious drug problem
  • Urine toxicology screening
  • Compton PJ, Darakjian J, Miotto K. Screening for addiction in patients with chronic pain and "problematic" substance use: evaluation of a pilot assessment tool. J Pain Symptom Manage 1998;16:355-63.
  • Katz NP, Sherburne S, Beach M, Rose RJ, Vielguth J, Bradley J, et al. Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg 2003;97(4):1097-102, table of contents.
predicting aberrant medication related behavior
Predicting Aberrant Medication-Related Behavior
  • A cutoff score of 8 was chosen to produce a sensitive test
  • Sensitivity of .90
    • Correctly classified 90% of the patients who actually went on to exhibit aberrant behaviors
  • Specificity of .69
    • 31% of the people, who scored an 8 or higher on the SOAPP, did not go on to show detectable aberrant behavior
slide54

14

12

10

8

Frequency

Mean = 19.06

SD = 8.258

6

N = 47

4

2

0

5

10

15

20

25

30

35

40

45

SOAPP Version 1.0 Summary Score

unexpected finding
Unexpected Finding
  • Biased population
    • Poorly controlled
    • Prescription drug abuse relatively common in ED setting
      • Short acting opioids
      • No opioid contracting
      • Multiple prescribers
  • Instrument not valid in ED
abusive behaviors and psychological factors
Abusive Behaviors and Psychological Factors
  • Prescription drug abuse will correlate with psychological factors
    • Previous study in pain clinics not confirmatory
      • “Psychosocial testing on clinic admission failed to predict who would become an opiate abuser”

Chabal C, Erjavec MK, Jacobson L, Mariano A, Chaney E. Prescription opiate abuse in chronic pain patients: clinical criteria, incidence, and predictors. Clin J Pain 1997;13(2):150-5.

correlates
Correlates
  • Self Efficacy for Coping with Symptoms
prescription drug use questionnaire
Prescription Drug Use Questionnaire
  • I believe that I am addicted to pain medicine
  • I routinely have to take more medication than my doctor prescribes in order to treat my pain
  • I prefer certain pain medications or ways of taking these medications (IV, IM routes over the oral route) 

Compton PJ, Darakjian J, Miotto K. Screening for addiction in patients with chronic pain and "problematic" substance use: evaluation of a pilot assessment tool. J Pain Symptom Manage 1998;16:355-63.

slide60

n = 47

Spearman rho

r = 0.223

p = 0.131

2-tailed

slide61
CAGE
  • Have you ever felt the need to Cut down on your use of prescription drugs?
  • Have you ever felt Annoyed by remarks your friends or loved ones made about your use of prescription drugs?
  • Have you ever felt Guilty or remorseful about your use of prescription drugs?
  • Have you Ever used prescription drugs as a way to "get going" or to "calm down?"

http://www.nida.nih.gov/ResearchReports/Prescription/prescription6.html#Providers

slide62

n = 45

Spearman rho

r = 0.322

p = 0.031

2-tailed

hx addiction legal issues
Hx Addiction/Legal Issues
  • Is there a history of alcohol or substance abuse in your family, even among your grandparents, aunts, or uncles?
  • Have you ever had a problem with drugs or alcohol or attended Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings? 
  • Have you ever had any legal problems or been charged with driving while intoxicated (DWI) or driving under the influence (DUI)?

Michna E, Ross EL, Hynes WL, Nedeljkovic SS, Soumekh S, Janfaza D, et al. Predicting aberrant drug behavior in patients treated for chronic pain: importance of abuse history. J Pain Symptom Manage 2004;28(3):250-8.

slide64

n = 45 Spearman rho

r = 0.418

p = 0.005

2-tailed

conclusions
Conclusions
  • Barriers are present
    • Similar to other settings
  • Chronic pain patients seeking care in ED are special population
    • Prescription drug abuse
      • More research needed
  • Short questionnaire for prescription drug abuse
    • No definitive answer
collaborators
Collaborators
  • Barth Wilsey MD
  • Ingela Symreng PhD
  • Amy Ernst MD
  • Dan Mungas PhD
  • Matt Lewis BS, Jeanna Millman BS, & Christine Ogden BS