Each month, Dr. Lynette Menefee tackles pressing issues in pain management with one of the nation's leading practitioners. This month, Dr. Menefee speaks with Knox Todd, M.D., Principal Investigator and Project Director for the Pain and Emergency Medicine Initiative. Dr. Todd is also on the faculty at Emory University School of Medicine. He speaks with us this month about pain management in the emergency room setting.

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Questions

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Dr. Lynette Menefee: Dr. Todd, it’s great to talk with you.

As an emergency medicine physician, you have certainly had the opportunity to be exposed to patients with pain and pain management options.

What made you interested in pain management as a focus in emergency medicine?

Knox Todd, M.D.: My interests grew from experiences in medical school and my early clinical training. The patient-physician interaction, from which all our diagnostic and therapeutic strategies flow, seemed to be given short shrift, particularly in my medical school years. The hospital in which I trained served an indigent, largely African-American population and the cultural gaps between the faculty and their patients created tremendous barriers to communication. Never was this difficulty more apparent than when pain was at issue. More often than not, there simply was no communication in this area.

During residency training, there was little or no instruction regarding the appropriate treatment of pain. In general, housestaff passed down pain management practices from one year to the next without critical examination by attending physicians. It seemed that the topic of pain management was outside the bounds of legitimate clinical training. I incorporated these values and practice patterns, and only after becoming frustrated with my ineffectiveness in treating many patients in pain over many years, did I gradually begin to question the basis of my practices and examine my own attitudes.

The specialty of emergency medicine developed in response to unmet needs within our health care system and public demand for timely service in the setting of emergent and urgent clinical conditions. Given this provenance, one might expect emergency physicians to be more responsive to patient needs. In our emergency departments, as you note, pain is ubiquitous. We find that fully sixty to seventy percent of patients seeking care in our departments do so because of pain. However, like traditional medical specialties, we tended to neglect pain as a symptom deserving of attention in and of itself, rather viewing it only as a guide to diagnosis. The lack of attention in our educational efforts to the principal reason patients sought our services seemed inconsistent with my view of emergency medicine and this led me to consider making it the focus of my career.

LM: There’s a stereotype of patients in pain waiting for hours to see an emergency department physician. Equally, there are stereotypes of patients coming to the emergency department seeking opioids. Are these accurate overall perceptions? How do you respond to these perceptions?

KT: It is true that emergency departments in the U. S. are critically overcrowded and that patients wait too long for care, not only for painful conditions. Among other reasons, this overcrowding reflects an altogether inadequate inpatient capacity as hospitals have continually cut costs in the face of decreasing reimbursement. At Grady Memorial Hospital in Atlanta, where I taught prior to taking on my current effort, we spent much of our time taking care of inpatients awaiting hospital beds, sometimes for days. In addition, we often serve as providers of primary health care for portions of our population that are ignored by our primary care system, or perhaps better termed, our primary care non-system. We spend much of our time practicing something other than emergency medicine, in response to such conditions.

In regard to stereotypes of patients coming to the emergency department seeking opioids, I feel that the vast majority of patients in pain who present to our departments seek pain relief primarily, rather than a specific class of analgesic. Of course we treat the addicted patient and the rare patient who seeks opioids for resale in the illegal market; however, requests for a specific class of analgesic much more commonly reflect the patients’ prior experiences with pain and their knowledge of what has worked for them in the past. It is our reaction to such requests that I find much more interesting. Particularly for patients with chronic pain and for the addicted, the emergency department physician-patient relationship is permeated by mistrust, and it is mutual. Given the frequency with which we treat the addicted and those with chronic pain syndromes, our lack of attention to, and knowledge of, addiction medicine and pain medicine is a tremendous barrier to rational practice.

LM: Do you and other emergency department physicians feel put on the spot sometimes? I mean, you probably don’t know most of the patients who come in to see you, some of whom request opioids. How do you weigh being cautious with treating patients?

KT: I referred earlier to our frustrations with a dysfunctional primary care system. We commonly see patients with complex medical conditions and treat them without the benefit of involving their office or clinic physician. This may be because they have no consistent care provider, often because they are among the most difficult patients. The “absent continuity physician syndrome” is much more likely occur when caring for a patient with chronic pain than for a patient with chronic congestive heart failure, to use one example, but is common in either case.

For patients seen infrequently, we simply make decisions in the face of severe inadequacies in our data. If one had to characterize my specialty in a few words, this condition of making decisions, sometimes critical decisions, in the face of inadequate data is not a bad description. (Additional phrases might include references to unrealistic time pressures and inadequate resources, but I do not think these are foreign feelings to my colleagues in many other medical specialties.) For the patient displaying possible addictive behaviors, emergency physicians tend to be extremely cautious. In my experience, we give much more weight to the possible harm caused by inappropriate opioid prescribing than to that caused by undertreating patients in pain. This issue is one important facet of our problems in treating pain adequately.

For the frequent emergency department visitor with chronic pain complaints, we have many more options available to us than we actually employ. Again, this is also true for many patients with chronic medical conditions other than pain. Active case management is an underutilized strategy that has been found repeatedly to be efficacious and cost-effective in caring for the “super-utilizing” emergency department patient. Although sometimes we find both recalcitrant patients and continuity care providers (including pain specialists) as we engage in this process, the results are much more rewarding than simply denying that solutions are possible.

LM: You are involved with large-scale studies in the US and Canada investigating how emergency departments treat patients with pain. What have you learned so far?

KT: First, I must acknowledge our supporters in making this effort possible. The Executive Director of The Mayday Fund contacted me a few years ago and expressed an interest in our specialty. Recently, we were given the opportunity to describe the specialty and our experiences with patients in pain at a meeting of the trustees. Subsequently, our team received grants in support of an effort to answer fundamental questions about emergency medicine and pain.

From previous single-institution studies we knew that pain was the most common reason for visiting the emergency department, that pain intensity levels both at presentation and discharge were high, and that certain patient subgroups were at higher risk for oligoanalgesia. In truth, patients were undertreated across the board. We had begun to tease apart possible causal mechanisms for such undertreatment, but had not performed the large-scale clinical epidemiology studies that ensured generalizability of our findings. In many cases, our study methodologies had not incorporated standard terminology or taken optimal advantage of standardized outcome measures. Importantly, we had little data on the chronicity of our patients’ pain and almost no follow-up data on patient outcomes.

We are embarking on a multicenter clinical epidemiology study involving over twenty sites in the U. S. and Canada in order to describe our patients with pain, determine treatment patterns in our departments, and perform telephone follow-up for a three-month period to assess multiple patient outcomes, including pain intensity, satisfaction with care, functional outcomes, health care utilization, and potential predictors of persistent pain. I am particularly interested in the transition from acute to chronic pain states, with an eye to modulation of the pain experience that might be possible in the emergency department phase of care.

LM: If there were one thing you could tell emergency department physicians about pain, what would it be?

KT: I think the first thing to emphasize is that we know less than we think we know. (Of course, this applies to all of medicine, hubris being medicine’s constant companion and worst enemy.) This lack of knowledge is not only characteristic of basic science, but is particularly pertinent to clinical practice and our understanding of the patient/physician interaction. Someone once said that medicine, rather than art or science, is most profitably considered a form of applied sociology. For clinical pain practice, this statement rings true. Clinical transactions regarding pain are social interactions, and the generalizations we make from insufficient evidence, and in many cases no evidence, can do much harm. The emergency department, where lack of continuity and time constraints make “snap judgments” routine and necessary, is particularly susceptible to these untoward effects. Our clinical heuristics, or rules-of-thumb, for dealing with pain problems remain largely unexamined.

LM: Thanks so much for talking to us Dr. Todd. We appreciate your expertise and all you are doing to promote appropriate pain management in the emergency room setting.

Stay tuned for next month’s interview with Dr. Todd, as he continues to examine pain management in the emergency room setting. Dr. Todd will look specifically at ethnic disparities in the treatment of pain.