Pain Management in the Addicted Patient: A Problem in the ED

An Expert Interview With Sergey Motov, MD, FAAEM

Steven Fox

March 09, 2011

March 9, 2011 (Orlando, Florida) — Editor's note: Patients who are addicted to drugs pose a special challenge when they present with pain at hospital emergency departments (EDs). Clinicians struggle with what medications to prescribe, and in what dosages. Societal bias against drug abusers may play a role in some ED personnel inappropriately withholding pain medications, even when there are valid indications for their use.

Such issues were the focus of an educational session presented here at the American Academy of Emergency Medicine 17th Annual Scientific Assembly. Medscape Medical News spoke with Sergey Motov, MD, FAAEM, assistant program director of the Department of Emergency Medicine at Maimonides Medical Center in Brooklyn, New York, about tactics for effectively dealing with addicted patients in the ED setting.

Medscape: You describe the inappropriate denial of analgesia to addicted patients as an "occupational hazard" in ED settings. How so?

Dr. Motov: The provision of analgesia for patients with drug addiction by some ED doctors is associated with preconceived bias and skepticism, derogatory attitude, and stigmatization. That often translates into denial of proper analgesics and opiophobia.

The overall impact of that in the ED is reinforcement of oligoanalgesia — underuse of analgesia in the face of valid indications — and diversion of these patients to illegal sources of pain medications.

Medscape: What are common signals ED personnel can use to help distinguish drug-addicted patients from those appropriately seeking relief from pain?

Dr. Motov: Patients with drug addiction are characterized by compulsive drug overuse and dose escalation, concurrent abuse of alcohol or illicit drugs, doctor shopping, and frequent hostility and verbal/physical abuse of ED personnel.

Often, however, when they present at the ED they appear somnolent, with slurred speech and shuffling gait — the classic picture of being "high."

Medscape: What are the most effective and practical strategies ED personnel can use to treat addicted patients in the ED setting?

Dr. Motov: Patients with addictive disease have the right to be treated with respect and to receive the same quality of pain management as all other patients. For patients in severe pain, parenteral analgesia with morphine, hydromorphone, or fentanyl is indicated.

These analgesics should be titrated up until pain is relived or side effects become intolerable. For patients in moderate pain, oxycodone or hydrocodone alone, or in combination with acetaminophen or ibuprofen, are warranted.

Medscape: You referred to so-called "Frequent Flyer Lists" in your presentation. What is meant by that?

Dr. Motov: These are mostly informal lists created and maintained by ED personnel of habitual offenders. The lists are aimed at controlling drug-seeking behavior in the ED by limiting or even denying opioid analgesia. However, no validated studies exist that evaluate their efficacy in combating drug-related aberrant behaviors in the ED. Unfortunately, these lists frequently promote undertreatment of acute pain and compromise patient privacy.

Medscape: Any specific advice for discharging patients, how much drug to prescribe, classes of medications to avoid, and so on?

Dr. Motov: When patients are discharged, they should be provided sufficient medication to relieve any anticipated pain, but less than might be used for abuse.

Oxycodone or hydrocodone in combination with acetaminophen, for 2 days, dosed at scheduled intervals, is often appropriate.

Acetaminophen-containing opioids are harder to abuse. However, it's important to keep in mind the potential for acetaminophen overdose, should all pills be taken at once. For that reason, it's best to provide the smallest amount of acetaminophen — 325 mg per tablet.

As to long-acting opioids, in a sense they're a double-edged sword. Use of long-acting opioids (controlled, extended release, or sustained formulations) is associated with fewer pills to be dispensed, constant blood levels, and fewer problems in controlling pain in a more stable manner. But if those medications are crushed and injected, significantly larger doses are released, and that creates a potential of serious overdose.

Medscape: Any special recommendations for treating patients who are on methadone maintenance?

Dr. Motov: Patients on chronic methadone therapy who are experiencing an acute exacerbation of chronic pain in the ED should be treated with parenteral morphine, hydromorphone, or fentanyl, with frequent titration of these medications. Use of parenteral methadone for treatment of acute pain should be avoided in the ED.

Medscape: What about buprenorphine-maintained patients? Any specific recommendations?

Dr. Motov: Buprenorphine has high affinity for opioid (Mu) receptors and tends to block action of other opioids in relieving acute pain. Intravenous titration of fentanyl helps to remove this block and to control acute pain.

Medscape: Do you have a take-home message for clinicians?

Dr. Motov: The clinical obligations of emergency physicians to treat acute pain outweigh any responsibilities in policing societal drug-related aberrant behaviors. Any expectation of curing chemical dependency and drug addiction in the ED is unrealistic.

Dr. Motov has disclosed no relevant financial relationships.

American Academy of Emergency Medicine 17th Annual Scientific Assembly. Presented March 4, 2011.

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