utilization of the emergency department by chronic pain patients to obtain pain medications: a study...
TRANSCRIPT
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 Center
Professor of AnesthesiologyUniv. of California, DavisSchool of Medicine
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: 51-7Wilsey, Fishman, Rose, Papazian, Pain management in the ED. Am J Emerg Med 2004; 22: 51-7
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
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• Study Structure• Method of Recruitment• Selected Population
~ Patient Demographics
~ Provider Demographics
• Status of Recruited Patients• Successful and Failed Recruitment
Techniques
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
• 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
• 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• 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
• 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
Patient Demographics: Gender
33
44
0
5
10
15
20
25
30
35
40
45
50
Num
ber o
f Pat
ient
s
Female
Male
n = 77
Patient Demographics: Duration of Chronic Pain
1
5
8
17
45
0
5
10
15
20
25
30
35
40
45
50
< 3 mo 3-6 mo 6mo-1yr 1-5yr 5+ yrs
Duration of Pain
Num
ber o
f Pat
ient
s
n = 76
Patient Demographics: Ethnicity
35
28
10
01
9
0
5
10
15
20
25
30
35
40
White Black American Indian Alaskan Native Asian or PacificIslander
Hispanic
Num
ber o
f Pat
ient
s
n = 83
Patient Demographics: Annual Income
33
16
7 7
31
0
3
0
5
10
15
20
25
30
35
< 10,000 10,001-20,000 20,001-30,000 30,001-40,000 40,001-50,000 50,001-60,000 60,001-70,000 70,001+
Dollars
Num
ber o
f Pat
ient
s
n = 70
Patient Demographics: Education
25
8
24
14
1 1
0
5
10
15
20
25
30
High School GED Some College Graduated college Masters Advanced Degree
Num
ber o
f Pat
ient
s
n = 73
Patient Demographics: Employment
18
55
0
10
20
30
40
50
60
Num
ber o
f Pat
ient
s
Employed
Not Employed
n = 73
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
Provider Demographics
Provider Demographics: Different Providers
14
5
36
1
0
5
10
15
20
25
30
35
40
Attending Resident Nurse Nursing Student
Nu
mb
er
of
Pro
vid
ers
n = 56
Provider Demographics: Gender
25
28
23.5
24
24.5
25
25.5
26
26.5
27
27.5
28
28.5
Num
ber o
f Pro
vider
s
Male
Female
n = 53
Provider Demographics: Ethnicity
41
1 2 20
2
0
5
10
15
20
25
30
35
40
45
White Black Asian Hispanic Indian Other
Num
ber o
f Pro
vide
rs
n = 48
Status of Study Subjects
Completers vs. Non-Completers
Completers vs. Non-Completers
39
51
0
10
20
30
40
50
60
Completers Non Completers
Num
ber
of
Pat
ients
n = 90
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
- CAGE Only : 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
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
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
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
Strongly disagreement
Moderate disagreement
Some disagreement
Some agreement
Moderate agreement
Strong agreement
Dunnett t-test post-hocns patient vs physician .113sig patient vs nurse .003
lack of time n=37 n=54 n=19nurse patient physician
0
1
2
3
4
5
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)
Strongly disagreement
Moderate disagreement
Some disagreement
Some agreement
Moderate agreement
Strong agreement
Dunnett t-test post-hocns patient vs physician .184ns patient vs nurse .075
more pressing issues n=37 n=54 n=19
nurse patient physician
0
1
2
3
4
5
Fatalism
• Provider• Chronic pain has
little chance of improving
• Patient• Chronic pain has
little chance of improving
Strongly disagreement
Moderate disagreement
Some disagreement
Some agreement
Moderate agreement
Strong agreement
Dunnett t-test post-hocsig patient vs physician .001sig patient vs nurse <.001
Little Chance of Improving
n=37 n=54 n=19patient physician nurse
0
1
2
3
4
5
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
Strongly disagreement
Moderate disagreement
Some disagreement
Some agreement
Moderate agreement
Strong agreement
Dunnett t-test post-hocsig patient vs physician .001sig patient vs nurse <.001
patient physician nurse
0
1
2
3
4
5
n=37 n=54 n=19
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
Strongly disagreement
Moderate disagreement
Some disagreement
Some agreement
Moderate agreement
Strong agreement
Dunnett t-test post-hoc sig patient vs physician .003sig patient vs nurse .001
n=37 n=54 n=19
Fear of Addiction
patient physician nurse
0
1
2
3
4
5
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
Strongly disagreement
Moderate disagreement
Some disagreement
Some agreement
Moderate agreement
Strong agreement
Dunnett t-test post-hocsig patient vs physician .018sig patient vs nurse <.001
n=37 n=54 n=19
Fear of Dependence
patient physician nurse
0
1
2
3
4
5
“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”
Strongly disagreement
Moderate disagreement
Some disagreement
Some agreement
Moderate agreement
Strong agreement
Dunnett t-test post-hoc ns patient vs physician .108ns patient vs nurse .313
n=37 n=54 n=19
“Drug Seeker”
patient physician nurse
0
1
2
3
4
5
Qualitative Research Through Interviews
• Access using conversations and consultations with ED physicians
• Taped and transcribed interviews» Anonymity and
confidentiality maintained
Qualitative Research
• Questions» Most problematic chronic pain patient» Limitations on care» Potential sources of improvement
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
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
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
Abusive Behaviors
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\
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
» 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)
• 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. http:/www.painedu.org.
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.
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.
Screener and Opioid Assessment for Patients in Pain (SOAPP)
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
5 10 15 20 25 30 35 40 45
SOAPP Version 1.0 Summary Score
0
2
4
6
8
10
12
14
Fre
qu
ency
Mean = 19.06
SD = 8.258
N = 47
• 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
Unexpected Finding
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.
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
• Self Efficacy for Coping with Symptoms
Screening for Prescription Drug Abuse in ED
3 or 4
simple
questions
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.
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.
n = 47 Spearman rhor = 0.223p = 0.1312-tailed
10 20 30 40
iSOAPP Score
0
0.5
1
1.5
2
2.5
3C
OM
PT
ON
SC
OR
E (
SU
M O
F P
OS
ITIV
ES
)
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#Providershttp://www.nida.nih.gov/ResearchReports/Prescription/prescription6.html#Providers
10 20 30 40
iSOAPP Score
0
1
2
3
4C
AG
E S
CO
RE
(S
UM
OF
PO
SIT
IVE
S)
n = 45 Spearman rhor = 0.322p = 0.0312-tailed
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.
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.
10 20 30 40
iSOAPP Score
0
0.5
1
1.5
2
2.5
3
JAM
ISO
N S
CO
RE
(S
UM
OF
TH
E P
OS
ITIV
ES
)
n = 45 Spearman rhor = 0.418p = 0.0052-tailed
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
• Barth Wilsey MD• Ingela Symreng PhD• Amy Ernst MD• Dan Mungas PhD• Matt Lewis BS, Jeanna Millman BS, &
Christine Ogden BS