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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.

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Presentation on theme: "Utilization of the Emergency Department by Chronic Pain Patients to Obtain Pain Medications: A Study of Barriers to Treatment, Abusive Behaviors and Psychological."— Presentation transcript:

1 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, MD Chief: Div. of Pain Medicine Dept. of Anesthesia & Pain Medicine UC Davis Medical Center Professor of Anesthesiology Univ. of California, Davis School of Medicine

2 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

3 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

4 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

5 Overview Study Structure Method of Recruitment Selected Population ~ Patient Demographics ~ Provider Demographics Status of Recruited Patients Successful and Failed Recruitment Techniques

6 Study Structure Visit 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

7 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

8 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

9 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

10 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

11 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

12 Patient Demographics: Gender n = 77

13 Patient Demographics: Duration of Chronic Pain n = 76

14 Patient Demographics: Ethnicity n = 83

15 Patient Demographics: Annual Income n = 70

16 Patient Demographics: Education n = 73

17 Patient Demographics: Employment n = 73

18 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

19 Provider Demographics

20 Provider Demographics: Different Providers n = 56

21 Provider Demographics: Gender n = 53

22 Provider Demographics: Ethnicity n = 48

23 Status of Study Subjects Completers vs. Non-Completers

24 n = 90

25 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

26 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

27 Summary of Recruitment Successful Strategies and Barriers

28 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 ~ 2 nd Visit does not receive as much of a response from patients ~ 2 nd 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

29 Quantitative Study of Barriers Questionnaire for Patients & Providers » Same questions ~Framed differently

30 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

31 Strongly disagreement patientproviders I do not have adequate time to assess and treat ED patients complaining of chronic pain ] ] Moderate disagreement Some disagreement Some agreement Moderate agreement Strong agreement Sig.001

32 Strongly disagreement Moderate disagreement Some disagreement Some agreement Moderate agreement Strong agreement Dunnett t-test post-hoc ns patient vs physician.113 sig patient vs nurse.003 lack of time n=37 n=54 n=19 nursepatientphysician ] ] ]

33 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)

34 Strongly disagreement Moderate disagreement Some disagreement Some agreement Moderate agreement Strong agreement Sig.021 patientproviders The treatment of chronic pain in the ED takes a back seat to treatment of more pressing issues like trauma or myocardial infarctions ] ]

35 Strongly disagreement Moderate disagreement Some disagreement Some agreement Moderate agreement Strong agreement Dunnett t-test post-hoc ns patient vs physician.184 ns patient vs nurse.075 more pressing issues n=37 n=54 n=19 nursepatientphysician ] ]]

36 Fatalism Provider Chronic pain has little chance of improving Patient Chronic pain has little chance of improving

37 Strongly disagreement Moderate disagreement Some disagreement Some agreement Moderate agreement Strong agreement Sig.000 patientproviders Chronic pain has little chance of improving ] ]

38 Strongly disagreement Moderate disagreement Some disagreement Some agreement Moderate agreement Strong agreement Dunnett t-test post-hoc sig patient vs physician.001 sig patient vs nurse <.001 Little Chance of Improving n=37 n=54 n=19 patientphysiciannurse ] ] ]

39 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

40 Strongly disagreement Moderate disagreement Some disagreement Some agreement Moderate agreement Strong agreement Dunnett t-test post-hoc sig patient vs physician.001 sig patient vs nurse <.001 patientphysiciannurse ] ] ] n=37 n=54 n=19 Belief in Pathology

41 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

42 Strongly disagreement Moderate disagreement Some disagreement Some agreement Moderate agreement Strong agreement Sig.000 patientproviders I believe that chronic pain patients who come to the ED are addicted to their pain medications ] ]

43 Strongly disagreement Moderate disagreement Some disagreement Some agreement Moderate agreement Strong agreement Dunnett t-test post-hoc sig patient vs physician.003 sig patient vs nurse.001 n=37 n=54 n=19 Fear of Addiction patientphysiciannurse ] ] ]

44 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

45 Strongly disagreement Moderate disagreement Some disagreement Some agreement Moderate agreement Strong agreement Sig.000 patientproviders I avoid administering opioids because patients will develop physical dependence and go through withdrawal when they abruptly halt the intake of the medicine ] ]

46 Strongly disagreement Moderate disagreement Some disagreement Some agreement Moderate agreement Strong agreement Dunnett t-test post-hoc sig patient vs physician.018 sig patient vs nurse <.001 n=37 n=54 n=19 Fear of Dependence patientphysiciannurse ] ] ]

47 “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”

48 Strongly disagreement Moderate disagreement Some disagreement Some agreement Moderate agreement Strong agreement Sig.058 patientproviders I find myself labeling chronic pain patients as "bad patients" or "drug seekers" ] ]

49 Strongly disagreement Moderate disagreement Some disagreement Some agreement Moderate agreement Strong agreement Dunnett t-test post-hoc ns patient vs physician.108 ns patient vs nurse.313 n=37 n=54 n=19 “Drug Seeker” patientphysiciannurse ] ] ]

50 Qualitative Research Through Interviews Access using conversations and consultations with ED physicians Taped and transcribed interviews » Anonymity and confidentiality maintained

51 Qualitative Research Questions » Most problematic chronic pain patient » Limitations on care » Potential sources of improvement

52 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

53 Estimated Numbers (in Millions) of Lifetime Nonmedical Use of Selected Pain Relievers among Persons Aged 12 or Older: 2002

54 Abusive Behaviors

55 Estimated Numbers (in Millions) of Persons Aged 12 or Older with Past Year Illicit Drug Dependence or Abuse, by Drug: 2002

56 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)

57 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 Screener and Opioid Assessment for Patients in Pain (SOAPP)

58 ~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: 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): , 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: 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): , table of contents. Screener and Opioid Assessment for Patients in Pain (SOAPP)

59 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

60 SOAPP Version 1.0 Summary Score Frequency Mean = SD = N = 47

61 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

62 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.

63 Correlates Self Efficacy for Coping with Symptoms

64 Screening for Prescription Drug Abuse in ED 3 or 4 simple questions

65 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:

66 n = 47 Spearman rho r = p = tailed

67 CAGE Have you ever felt the need to C ut down on your use of prescription drugs? Have you ever felt A nnoyed by remarks your friends or loved ones made about your use of prescription drugs? Have you ever felt G uilty or remorseful about your use of prescription drugs? Have you E ver used prescription drugs as a way to "get going" or to "calm down?"

68 n = 45 Spearman rho r = p = tailed

69 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.

70 n = 45 Spearman rho r = p = tailed

71 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

72 Collaborators Barth Wilsey MD Ingela Symreng PhD Amy Ernst MD Dan Mungas PhD Matt Lewis BS, Jeanna Millman BS, & Christine Ogden BS


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