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Chronic Pain and the ER Visit
By Mary L. Meyer, Manager and Knox H. Todd, MD, MPH, Director
Pain and Emergency Medicine Institute

Emergency Departments (EDs) are designed to respond to the most obvious and urgent medical needs. Assessment, prioritizing, and treatment happen quickly. This is the opposite of what is needed to treat chronic pain. Chronic pain is a complex phenomenon and it is often not amenable to a straightforward, standardized treatment approach. Nonetheless, when severe pain hits, the ED may be the only option available.The purpose of this article is to help chronic pain sufferers understand better the unique environment of the ED and how that might affect the care they are given, and to suggest some ways that this encounter can be made more productive.

Barriers to effective Treatment - A relationship of strangers
•The patient-physician relationship in the emergency department is frequently one between strangers. There is no shared history or understanding of the complexity of the patient's situation.
• Most physicians receive very little training in pain management, so it is not surprising that emergency physicians may not be skilled in the management of a complex chronic pain condition, such as reflex sympathetic dystrophy. If they have no experience or skill in dealing with the condition that is presented to them, they may tend to minimize the seriousness of the condition, and unconsciously shield themselves from the patient's distress.
• Many patients with chronic pain might know more than the treating physician about the medications needed for effective treatment of their conditions. However, if patients are too adamant in their demands for particular drugs, it can cause physicians to become suspicious of their motives.
• Emergency physicians are very concerned that patients might use the ED to obtain controlled substances because of addiction or for criminal purposes. Physicians may fear prescribing large doses of opioids (narcotics) to control pain they do not understand. Recent activities of the Drug Enforcement Administration to control illicit prescribing by physicians also contributes to this climate of fear.

What can a patient do?
1. If you have a primary care provider who knows your situation, it will be enormously reassuring to the ED physician if he or she is aware that you are seeking care in the ED and your PCP can be contacted. It might help to ask your physician for a letter that states you are under care, a description of the pain condition, and how it is being managed. You should take this document with you when you go to the ED. The letter should contain contact information for your physician.
2. Always keep handy a list of the medications and dosages you are taking to bring with you to the ED. This will help the physician know what additional drugs can be prescribed safely.
3. Be patient with the caregivers. Remember, you are a stranger to them. When you are in pain this is a hard thing to ask, but becoming angry with your caregivers may alienate them, increase their suspicions of your motives, and lessen the chances that your treatment will be successful.
4. If you have a less than optimal experience in the ED, write a follow-up letter to the hospital patient advocate describing your treatment. If it was not accomplished during the visit, ask your physician to communicate with the ED. This will be very helpful in establishing a relationship should you need emergency services in the future.

Mary L. Meyer, Manager
Knox H. Todd, MD, MPH, Director
Pain and Emergency Medicine Institute
From:
The Pain and Emergency Medicine Institute
Department of Emergency Medicine
Beth Israel Medical Center
Albert Einstein College of Medicine
First Avenue at 16th Street
New York, NY 10003
Tel: 212 420 2813
Email: ktodd@chpnet.org

Executive Director's Comment
In our recent Internet survey conducted by the Johns Hopkins School of Medicine, we included a number of questions on the ER experience of people with CRPS. These are their responses.