The first problem with this article is the title, "Managing Chronic Pain in the ED". This article really has nothing to do with managing chronic pain in the ED. It should be called, "How not to contribute to drug abuse and diversion in the ED". The two are not the same, and that is the main fault of this piece.
Unfortunately, this is a very common misperception in the ED that chronic pain EQUALS "drug abuse and diversion". Part of this is lack of knowledge as to how much more there is to the specialty of Pain Management other than opiate prescribing. The average EM physician, accept possibly those in a tertiary academic ED with a strong Pain department, may never have even heard of a dorsal column stimulator, medial branch radio frequency ablation, suprascapular nerve block, transforaminal ESI, and so on.
Also, in the ED it is much, much more difficult to stratify patients as to how "legit" they are. There's no PCP note or referral. There's no ability to get old records. There's no ability to get a UDS with specific drug breakdown. ID isn't even required to be seen in the ED, so in these cases a prescription monitoring website is worthless.
The other part is the horrendously skewed subsegment of patients the ED sees that represent themselves as "chronic pain" patients. Anyone discharged from a Pain practice goes first, where? An ED. Those with Medicaid that can't get into any legitimate Pain clinic, rather than waiting 3 months to go to the only local PCP that still takes Medicaid, they go to the ED. Those that were on a large dose of opiate and lost their insurance and have run out of meds, when they go into withdrawal, go to the ED. In unbearable pain at 2am on a holiday when the Pain practice is closed? Off to the ED they go. Mixed in are a good number of patients with acute exacerbations of chronic pain who have done everything right, yet end up in the ED for whatever reason. These patients, because of the context, unfortunately are often still viewed with great suspicion.
In private practice Pain Medicine, there is the ability to pre-screen, filter, reassess and triple-distill our patient population so that the patient mix, payor mix, compliance level, and personality of the patient fits that of the doctor to a level radically more possible beyond that in the ED (I know that's hard to believe we have the "good ones", but it's true). In the ED, they have to deal with a 100% un-adultered, drunk, tired, high, angry, broke, psychotic, uninsured, steaming humanity, faster than anyone would want to, with traumas, cardiac arrests and codes heaped on top with administration expecting them all to be seen in 30 min or less with "highly satisfied" Press Gainey patient satisfaction surveys.
The article, like you said, says virtually nothing about how to treat chronic pain, and only mentions how to identify diversion, while at the same time equating all chronic pain with diversion. This is grossly flawed, and incomplete. In the context of a patient population, however, that is filtered and sub-filtered to concentrate the "worst of the worst" by no fault of those in the EDs, compared to a Private Pain practice where patients are pre-screened and further selected and re-selected over time for the best insurance, best compliance and least aberrant behaviors, I get it.
In context, I get it.
