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Advanced Emergency Nursing Journal

Vol. 29, No. 1, pp. 3540
Copyright c
2007 Wolters Kluwer Health | Lippincott Williams & Wilkins
Cases
O F N O T E
Column Editor: Karen Hayes
A Challenging Case of Chronic Pain
in the Emergency Department
Medical and Ethical Issues
of Management
Courtney Reinisch, MSN, RN, APN-C
Abstract
Pain is a common problem seen in all areas of healthcare including the emergency department
(ED). Chronic pain is a condition that requires specialized management. EDs provide episodic care
and are often faced with the challenge of managing patients with chronic pain. Some of these
patients present with drug-seeking behaviors that make it difcult to provide appropriate care for
their condition. This article presents a case of a patient with chronic migraine headache, and the
ethical issues surrounding her management in an ED, with focus on the patients autonomy, and
the concepts of nonmalcence, benecence, and informed consent. This article concludes with
recommendations for EDto appropriately and safely manage patients with chronic pain. Key words:
autonomy, benecence, chronic pain, drug-seeking behavior, ethical issues in emergency care,
informed consent, nonmalcence
M
rs H was a 45-year-old woman be-
ing treated for migraine headaches
by a psychiatric neurologist after
other organic problems had been ruled
out. Her oral medication regimen included
gabapentin, topirimate, and propranolol for
headache prophylaxis and oxycodone for
breakthrough headaches. When necessary,
her physician administered intramuscular in-
jections of meperidine and hydroxyzine for
From the Robert Wood Johnson University Hospital,
Hamilton, NJ; and the School of Nursing, Columbia
University, New York, NY.
Corresponding author: Courtney Reinisch, MSN, RN,
APN-C, School of Nursing, Columbia University, New
York, NY 10032 (e-mail: cer2117@columbia.edu).
breakthrough pain. The patient and her physi-
cian had a contract stating she would only
take the narcotic medications that he pre-
scribed and she would not go to the emer-
gency department (ED) for pain medications.
Mrs Hhad been employed as a licensed practi-
cal nurse, however, because of her condition,
her license had been suspended.
Mrs H did not maintain her contract. She
visited multiple EDs, requesting pain medi-
cations including meperidine and hydromor-
phone. If the first ED provider refused treat-
ment with narcotics, she would go to the next
local ED and demand the same medications.
According to Mrs Hs spouse, she also ob-
tained narcotics illegally.
35
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36 Advanced Emergency Nursing Journal
After several years, the patient and her
treating physician agreed that she needed re-
habilitation for her narcotic addiction, and
she attended an inpatient program. Upon dis-
charge, she relapsed and resumed her pre-
vious behavior, visiting local EDs demanding
narcotic pain medications.
The staff within our ED recognized the se-
rious nature of her condition and developed a
plan to contact her treating physician at each
visit. Her physician recommended that we in-
ject the patient with saline and tell her we
were giving her meperidine, which was the
practice in his office. The ED staff felt this
course of action was dishonest, unethical, and
illegal.
Given the treating physicians recommen-
dation to use a placebo, managing the
patients condition in the ED remained a chal-
lenge. The patients aggressive behavior esca-
lated. She threatened to harmmembers of the
ED staff if they would not treat her with nar-
cotic pain medications. She displayed manip-
ulative behavior by requesting to be seen by
providers she believed would treat her with
her drug of choice. These providers complied
with her demands to facilitate her discharge
without incident from the ED. When advised
that she could not select her provider in the
ED, she would leave before being seen, and
subsequently file a complaint stating she was
not being treated fairly because her request
to be seen by a particular physician was not
honored.
The patients behavior and frequent vis-
its were a source of contention for ED
providers. Some providers would treat Mrs
H with whatever medication she requested,
while others refused to treat her with nar-
cotics due to her addiction and worsening
condition and violation of contract with her
neurologist.
The patients clinical status continued to
deteriorate. Her speech was slurred. She
walked with a shuffling gait, and had tremors.
Given her presentation, some providers re-
fused to evaluate this patient, leaving her to
be seen by another provider. The patient did
not want to be treated by the advanced prac-
tice nurses because she felt they were less
likely to treat her with narcotics. The ad-
vanced practice nurses, as a group, felt that
treatment with narcotics was not in her best
interest, and would cause more harm than
good.
Current guidelines on appropriate treat-
ment of pain in the ED further impacted this
patient care dilemma. The Joint Commission
on Accreditation of Healthcare Organizations
states that pain is undertreated and mandates
pain be assessed as the fifth vital sign. Accord-
ing to the commission, a provider must be-
lieve a patient to be experiencing the level of
pain he or she reports and to treat the pain
appropriately.
The patients behavior compelled our ED
personnel to examine the ethical issues sur-
rounding this case. The issues of pain man-
agement in the presence of addiction needed
to be discussed in relation to the ethical prin-
ciples of autonomy, nonmalficence, benefi-
cence, and informed consent. The hospitals
risk management team and the patients neu-
rologist were consulted to determine what
could ethically and legally be done for this pa-
tient since EDs are required to stabilize every
patient that enters the department regardless
of sex, race, medical condition, and ability to
pay.
As a result of the meetings, risk manage-
ment and the ED staff reached an agree-
ment. The following actions were taken. A
certified letter was sent to the patient advis-
ing her that ED personnel would no longer
treat her migraines with narcotic medications.
She would be evaluated and treated with
the nonnarcotic headache medications rec-
ommended by her neurologist. This decision
was based on the premise that emergency
care is episodic in nature and treatment of
her condition required specialized manage-
ment from a headache or pain specialist. All
providers in the ED signed the letter. The
letter was carefully worded to ensure that
the patient understood she was welcomed
in the department, but that narcotics would
no longer be administered for this particular
condition.
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Vol. 29, No. 1 Chronic Pain in the Emergency Department 37
DISCUSSION OF CONTEXT AND ETHICAL
PRINCIPLES
Drug-Seeking Behavior for Pain Management
Pain is the most common presenting com-
plaint to a physicians practice (Weaver &
Schnoll, 2002). Pain can be classified as
acute, lasting from time of injury to 2 weeks;
subacute from 2 weeks to 3 months; and
chronic, lasting beyond 3 months (Vukmir,
2004). Chronic pain is defined as persistent
or episodic pain of a duration or intensity that
adversely affects functioning and well-being
of the patient attributable to any nonmalig-
nant etiology (Vukmir, 2004). Chronic, non-
malignant pain accounts for 10% to 16% of
outpatient visits and 25% to 40% of hospital-
izations (Weaver & Schnoll, 2002).
Pain drives drug seeking for opioids in both
animals and humans. This causes increased
drug-seeking behaviors and cravings in pa-
tients with substance use disorders (Trafton,
Oliva, Horst, Minkel, & Humphreys, 2004).
Pain is often associated with mental health
problems and functional and social disabil-
ity. Patients in pain have increased rates of
depression, anxiety, suicidal ideation, and hal-
lucinations. Depression rates increase with
increasing rates of pain (Trafton et al., 2004).
Problematic behaviors such as health com-
plaints, decreased physical function, illicit
drug use, mood disorders, healthcare uti-
lization, and suicidal ideation all increase
with pain. Pain intensity may be a driving
force behind undesirable patient behaviors
(Trafton et al., 2004).
Drug-seeking behavior occurs with both
active addiction and pseudoaddiction. Drug-
seeking behavior for pain relief is defined
as pseudoaddiction. This behavior will in-
crease if pain is not adequately controlled.
To avoid pseudoaddiction, providers must be-
lieve patient complaints are legitimate. Ini-
tially, it is nearly impossible to distinguish be-
tween an addict who seeks increasing levels
of pain medications for euphoria compared
with a patient in pain who has undertreated
pain. Once pain is appropriately managed,
providers can distinguish between addic-
Table 1. Drug-seeking behaviors
1. Multiple visits
2. The inability to focus on anything other
than the medication
3. Lost prescriptions
4. A primary provider that is not available
5. Allergy to alternative medications
6. A desires for narcotics
7. Substitutes benzodiazepines
8. Common complaints include headache,
ureteral colic, toothache, and abdominal
pain
9. Pain is described as unbearable
10. Overly creative requests
11. Appearance change or use of alias
Note. Adapted from Vukmir (2004).
tion and pseudoaddiction (Weaver & Schnoll,
2002).
Patients demanding behavior to obtain
medications can cause them to claim an al-
lergy to nonaddictive medications, report a
high tolerance to drugs, may lose a nar-
cotic prescription, or claim to run out early.
Doctor shopping is another common drug-
seeking behavior where the patient sees mul-
tiple providers to obtain an adequate or
increasing supply of prescription narcotics.
These patients are often seen in EDs, after
hours, or reporting that they are from out
of town (Longo, Parran, Johnson, & Kinsey,
2000). Patients with drug-seeking behaviors
may present with a variety of complaints or re-
quests, as identified in Table 1 (Vukmir, 2004).
Assessment and treatment of pain in the ED
is unique and presents challenges. Problem
categories include patients with chronic pain
who need specialized follow-up and do not
benefit fromadditional analgesics given in the
ED. It may be difficult to assess and identify
those who seek and abuse drugs within the
ED setting (Vukmir, 2004).
Depression, hospitalizations, and suicidal
ideation improve with adequate pain control.
Appropriate pain management may help pa-
tients with substance use disorder to con-
trol their illicit substance use (Trafton et al.,
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38 Advanced Emergency Nursing Journal
2004). Dissatisfaction with pain management
is more likely with more severe pain, as well
as higher rates of depression, anxiety, and al-
tered mental status (Vukmir, 2004). Pain man-
agement is difficult because it relies on subjec-
tive data with little objective support. There
is a greater success in managing pain with a
long-term patient relationship as opposed to
the brevity of an ED visit (Vukmir, 2004).
Given the high prevalence of chronic pain
and the limited availability of pain manage-
ment resources, particularly for populations
served by the ED, pseudoaddiction is the
most likely cause for a large proportion of
drug-related behaviors deemed aberrant. Pa-
tient reports of distress associated with un-
relieved symptoms, aggressive complaining
about the need for higher doses, and patient
dose escalation are signs of pseudoaddiction.
The hallmark of pseudoaddiction is that aber-
rant behaviors disappear when adequate anal-
gesics are given to control pain (Todd, 2005).
Table 2 illustrates behaviors more or less con-
sistent with addiction.
Autonomy
Personal autonomy is defined as self-rule that
is free from both controlling interference by
others and from limitations such as inade-
quate understanding that prevents meaning-
ful choice (Beauchamp & Childress, 2001).
Autonomous persons with self-governing ca-
pacities sometimes fail to govern themselves
in particular choices because of temporary
constraints caused by illness or depression or
because of ignorance, coercion, or other con-
ditions that restrict their options (Beauchamp
& Childress, 2001). Respect for autonomy is
a professional obligation in healthcare, and
autonomous choice is a right of patients
(Beauchamp & Childress, 2001).
Although Mrs H continued to be au-
tonomous, she ceased to be able to make
decisions that were in her best interest due
to her worsening condition. She was impaired
because of her drug-seeking behavior, and dis-
abled as a result. She was unable to be an
active participant in her care due to her de-
Table 2. Spectrum of aberrant drug-related
behaviors that raise concern about the poten-
tial for addiction
Less suggestive of addiction
Aggressive complaining about the need
for more drug
Drug hoarding during periods of reduced
symptoms
Requesting specific drugs
Openly acquiring similar drugs from other
medical sources
Occasional unsanctioned dose escalation
or other noncompliance
Unapproved use of the drug to treat
another symptom
Reporting psychic effects not intended by
the clinician
Resistance to a change in therapy
associated with tolerable adverse
effects with expressions of anxiety
related to the return of severe symptoms
More suggestive of addiction
Selling prescription drugs
Prescription forgery
Stealing or borrowing drugs from others
Injecting oral formulations
Obtaining prescription drugs from
nonmedical sources
Concurrent abuse of alcohol or illicit
drugs
Repeated dose escalation or similar
noncompliance despite multiple
warnings
Repeated visits to other clinicians or
emergency departments without
informing the prescriber
Drug-related deterioration in function at
work, in the family, or socially
Repeated resistance to changes in therapy
despite evidence of drug effects
Note. From Opioids for Nonmalignant Pain: Issues and
Controversy, by C. L. Shalmi (cited in Warfield & Bajwa,
2004).
sire to reach her goal of obtaining her drug of
choice. It is reasonable to question whether
treating this patient in the EDalso contributed
to her drug-seeking behavior and addiction.
Some providers who would treat her with
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Vol. 29, No. 1 Chronic Pain in the Emergency Department 39
increasing doses of narcotics reinforced the
patients behaviors. In addition, those who
would not treat her and put her into with-
drawal may have increased her pain.
Nonmalcence and Benecence
The concept of nonmalficence can be de-
fined as the obligation to intentionally do
no harm, whereas beneficence can be de-
fined as the obligation to promote or do good
(Beauchamp & Childress, 2001). Generally,
healthcare providers are caring individuals at-
tempting to keep their patients from receiv-
ing harmful treatments while providing bene-
ficial care to their patients.
In Mrs Hs case, it was difficult to de-
termine which treatment would deliver the
greatest benefit without causing harm. Some
providers felt that treating her pain would
be harmful for her condition, thus worsen-
ing her drug-seeking behaviors. Other care-
givers felt that providing narcotic pain treat-
ment in the acute arena would be the only
reasonable choice. She would receive tempo-
rary pain relief and avoid withdrawal symp-
toms. The question in this patients manage-
ment was whether the healthcare providers
caused her harm by treating her with nar-
cotics, a contributing factor to her present-
day addictive behaviors. Obviously, the out-
come was not intentional. Providers would
have not prescribed narcotics if they thought
this patient would become addicted. This was
an unfortunate outcome of attempting to ben-
efit the patient by offering pain relief. Over
time, what was once a beneficial treatment
became a detriment.
Informed Consent
When initiating the prescription for nar-
cotic pain medications, patients need to
be informed of the potential for physical
dependency, as well as the possibility of
mild-to-moderate rebounding when the
medication is discontinued (Longo et al.,
2000). An informed consent is an individuals
autonomous authorization of a medical
intervention (Beauchamp & Childress, 2001).
Informed consent is obtained in some con-
text for medicines for which shared decision
making is not possible.
Mrs H was unable to truly give informed
consent for any treatment because she was of-
ten under the influence of a variety of sub-
stances. She was driven to obtain narcotics
that did not allow her to consider risks and
benefits of treatment. Participation in her care
was not a motivation. Healthcare providers
lost objectiveness due to her escalating drug-
seeking behaviors.
Emergency Department Management
Given the volume of patients with substance
abuse disorders, the ED is an appropriate site
for screening and intervention for both alco-
hol and drug problems. However, some ED
providers receive limited training in recogni-
tion and appropriate interventions for such
problems (Todd, 2005). Emergency care is
episodic by design, with multiple providers
providing care. These patients require close
observation and treatment by pain specialists
or drug addiction specialists, depending upon
the particular case. Close attention needs to
be paid to these patients to ensure that they
receive the specialized level of care they de-
serve (Todd, 2005). Therefore, what should
EDs do when faced with these patients? There
is paucity of treatment guidelines and best
practice standards for ED pain care, in part,
because there is a lack of research in this area
by emergency medicine investigators (Todd,
2005). However, the American College of
Emergency Physicians (ACEP) offers a policy
statement for pain management in the ED
(ACEP, 2004) (Table 3).
Our profession should abandon the term
drug-seeking behavior, since for the patient in
pain, seeking an analgesic is the height of ra-
tionality. Aberrant drug-related behaviors as
the term suggests is a broad range of behav-
iors that are acceptable in the context of pain
therapy (Todd, 2005). On the basis of research
in this topic, recommendations for future
cases may include developing local policies,
patient referral, and consult, and educating
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40 Advanced Emergency Nursing Journal
Table 3. American College of Emergency Physicians (ACEP) policy statement on pain manage-
ment in the emergency department (ED)

The majority of ED patients require treatment for painful medical conditions or injuries. The
ACEP recognizes the importance of effectively managing ED patients who are experiencing
pain and supports the following principles:
ED patients should receive expeditious pain management, avoiding delays such as those related
to diagnostic testing or consultation.
Hospitals should develop unique strategies that will optimize ED patient pain management using
both narcotic and nonnarcotic medications.
ED policies and procedures should support the safe utilization and prescription writing of pain
medications in the ED.
Effective physician and patient educational strategies should be developed regarding pain
management, including the use of pain therapy adjuncts and how to minimize pain after
disposition from the ED.
Ongoing research in the area of ED patient pain management should be conducted.

Approved by the ACEP Board of Directors, March 2004.

ED providers regarding pain management
(Table 4).
Since relieving pain and reducing suffering
are primary responsibilities of EDs, much can
be done to improve the care of patients in
pain. Providers have a duty to limit the per-
sonal and societal harm that can result from
prescription drug abuse. ED providers need
to refine the approach to the problem of pain
and substance abuse and reduce the current
large amount of variability in our practices.
Standards for excellence in pain practice and
substance abuse interventions need to be de-
Table 4. Pain management recommenda-
tions
1. Develop a local policy for the
management of acute and chronic pain
2. Refer patients with chronic pain
syndromes to pain management
specialists for outpatient management
3. Consult with pain management or
addiction specialists for patients with
identified narcotic abuse issues in the
emergency department (ED)
4. Educate ED providers and nurses in the
topic of pain evaluation and treatment
veloped while promoting quality to achieve
these goals (Todd, 2005).
REFERENCES
American College of Emergency Physicians. (2004). ACEP
policy statement: Pain management in the emergency
department. Annals of Emergency Medicine, 44(2),
198.
Beauchamp, T. L., & Childress, J. F. (2001). Principles of
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