Visiting the ER for Chronic Pain

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Updated: 11/02/2011 9:53 am

You’re a chronic pain patient who takes several prescription narcotics to control your symptoms. Then one weekend, excruciating pain lands you in the emergency room. There, a doctor grills you about your medications, in part to make sure that you’re a legitimate pain patient, not someone seeking drugs. What can you do to help the ER doctor to believe you?

It’s not always easy to tell chronic pain patients from drug-seeking patients, says Howard Blumstein, MD, FAAEM, president of the American Academy of Emergency Medicine and medical director of the North Carolina Baptist Hospital emergency room.

Patients with chronic pain visit the ER for various complaints, he says. “Some of these patients have demonstrable disease, like sickle cell disease or chronic pancreatitis. I think that physicians are more likely to give them the benefit of the doubt when they come in and say they have pain.”

“Other patients are prone to have problems that you can never objectively demonstrate, like chronic back pain and chronic headaches,” he says. “We just have to take their word for it. You can’t look into anything and tell whether or not they’re actually having pain.”

Regardless of which group patients fall into, Blumstein says, “there are some patients who, because of their behavior or their frequent visits, still get labeled as being addicted to drugs or abusing drugs.”

What type of behavior raises suspicions? “Patients will come in and be very demanding, get into fights with doctors and nurses because they don’t think they’re getting enough pain medicine, and that causes the health-care providers to become suspicious of the patient’s motives,” he says. Or the patient may ask for a specific narcotic like Demerol, or say they’re allergic to non-narcotic pain relievers.

Understanding Suspicion in the Emergency Room

“In most cases, it’s probably unfair to the patient,” Blumstein says. But emergency room doctors have strong motivations to carefully screen out drug seekers. They want to thwart drug abuse and any chance that narcotics will be diverted, for example, sold to strangers, or exchanged for illegal substances. “They have a high street value,” Blumstein says.

ER doctors have one useful tool, though. Currently, 34 states have prescription drug monitoring programs that allow doctors to check a patient’s prescription history online. “I can look up a patient and see all the prescriptions that have been filled for controlled substances,” says Blumstein, who practices in North Carolina. Doctors can use the database to corroborate a patient’s story. Or they might see patterns that warn them to probe further for drug abuse, for example, prescriptions from numerous physicians that have been filled at multiple pharmacies.

“It is an unbelievably great tool for physicians,” says Eduardo Fraifeld, MD, president of the American Academy of Pain Medicine.

But ER doctors also rely on instincts, Blumstein says. “It’s all perception. It’s the whole gut impression that the health-care providers get about you.”

So how can a patient with chronic pain convince the ER staff that his or her complaints are legitimate? Here are a few tips from the pain experts:

1. Make sure that you have a regular physician who treats your chronic pain.

That’s a relationship that all chronic pain patients should establish before they ever set foot in an emergency room, Blumstein says. But many people don’t have a doctor, he says, “and it looks really bad from a doctor’s point of view when a patient comes in and says, ‘Oh, I have this terrible chronic pain,’ and the doctor says, ‘Who’s taking care of this terrible chronic pain?’ and the patient says, ‘Oh, I don’t have a doctor.’”

“Before you get into a situation where there’s an exacerbation of your condition, make sure you have a regular doctor treating you,” he says.

2. Show that you’ve tried to contact your regular doctor before you go to the ER.

If you’ve been in pain for five days and have not alerted your doctor, the ER staff will question how bad your pain really is, Blumstein says. Even if the pain struck just that day, make an effort to contact your regular doctor first, he suggests.

ER staff will be more sympathetic to patients who have called their doctors and been told to go to the emergency room because the doctor was unable to see them, Blumstein says. “At least you’re showing you made an effort. You’re using the emergency room as your treatment of last resort, as opposed to the primary place you go for pain medication.”

3. Bring a letter from your doctor.

“A letter from your physician, with a diagnosis and current treatment regimen, is a reasonable thing to carry with you,” Fraifeld says. “Particularly if you’re on chronic opioids in today’s atmosphere, I would highly recommend that to patients.” 

Make sure the letter has your doctor’s name and phone number, Blumstein says. That way, if ER doctors want to contact your physicians, they can. A letter is especially useful if you’re traveling or going to a hospital that you’ve never visited before.

It’s fine to bring medical records, too, Fraifeld says. But don’t overdo it, Blumstein says. “I’ve had patients come in with tons of records -- I mean, you could measure the stack in inches. It just looks like you’re going overboard.” 

4. Bring a list of medications.

Bring a list of your medications, instead of relying on memory, Blumstein says.

Fraifeld takes it one step further and suggests that patients bring the drugs. “Take all the pain prescriptions with you -- the actual bottles -- not just the list,” he says. “[Patients], I’m sad to say, highly contribute to their own problems by not even being able to tell physicians exactly what they’re getting and when they got it and whom they got it from.”  

5. Work cooperatively with emergency room staff.

“It might not be fair, but if a patient comes in screaming and shouting that they need pain medication right away, the staff isn’t going to like it. It calls negative attention to yourself,” Blumstein says. “And it is unfair, because you might be having agonizing pain, and why shouldn’t you speak up for yourself, right? But a lot of staffs don’t like it and they don’t respond well to it. So rather than demand things, try to work cooperatively with the staff.”

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