Citywide Initiative Targets Chronic Pain

ACEP News
July 2010

By Doug Brunk
Elsevier Global Medical News

0710 Chronic Pain
Dr. Thomas D. Meyer has launched a program aimed at reducing repeat ED visits by chronic pain patients at three Madison, Wisc., hospitals.

An initiative launched by a Wisconsin emergency physician could become an effective prescription for curbing repeat visits to the emergency department by patients with chronic pain.

The project is known as the Madison Citywide ED Chronic Pain Quality Improvement Initiative. Patients who visit the ED in one of the city's three major hospitals more than 10 times per year with chronic pain as their chief complaint receive a letter stating that they can no longer receive narcotics in the ED. The patient's primary care physician then receives a copy of the letter, the intent of which is to open a dialogue about optimal pain management.

"When I initially did this, I was fairly apprehensive, because I was thinking the primary care doctors would be upset that I was dumping all these patients back on them," said Dr. Thomas D. Meyer, an emergency physician at the University of Wisconsin Hospital and Clinics in Madison. "But almost universally I got support, because what I was doing was contributing to their ability to establish consistent pain management guidelines for their patients."

Standard emergency medicine textbooks, as well as guidelines from the American Academy of Pain Management, state that opioid treatment of chronic pain "should only be used if it enhances a patient's ability to function in society, with family, or at work," Dr. Meyer said. "Escalating that dose, obtaining prescriptions from multiple providers, and requesting refills for lost pills are all signs that they really should have their pain contract reassessed.

"I'm not saying these patients shouldn't have opioids--I think some people actually function better with opioids to manage their pain," he added. "But they need a consistent and controlled approach."

In a pilot study of the initiative carried out on 15 patients who averaged 19 visits per year to the ED for complaints related to chronic pain, the number of visits dropped to just 2 per year in the subsequent year (Am. J. Emerg. Med. 2007;25:445-9). Visits with primary care physicians also dropped from an average of 19 visits per year to 7 visits.

Before he launched the pilot study, Dr. Meyer struggled to get buy-in from some of his physician colleagues. Ultimately, he and his associates selected a target population of patients with chronic, noncancer, non-sickle cell pain who had been in the ED more than 10 times in the past year. The patients also had to have primary care doctors who could manage the patients' pain.

Shortly after the pilot study, Dr. Meyer learned that increasing numbers of patients were visiting the EDs of other area hospitals for pain-related complaints. So, he met with leaders of the EDs in Madison's two other major hospitals--Meriter Hospital and St. Mary's Hospital--to propose expansion of the initiative.

In early 2009, the leaders of all three hospitals agreed on a single letter that would be sent to chronic pain patients who frequently visited the ED, as well as a single set of criteria for deciding when patients should receive the letter. "The only downside of this is that, after we launched the initiative, we didn't keep communicating with each other as much as we should have," Dr. Meyer said.

In light of HIPAA restrictions, "we initially found that communicating patient selection between hospitals was problematic," he said. Recently, the hospitals began using the same electronic medical records system. That enabled Dr. Meyer and his colleagues at the other two hospitals to begin beta-testing software that allows them to share medical records after initial patient consent. "As a result, communication efforts have improved significantly," he said.

Dr. Meyer noted that his visits with chronic pain patients who frequent the ED are more productive if they have received the letter. "When we don't get into arguments about long-term management of their pain, we can focus on present symptoms and findings, and make non-opioid recommendations for care," he said.

Further expansion of the initiative in the Madison area will be limited until there are improvements in software design, Dr. Meyer said. In the meantime, interest in the program outside Madison appears to be on the upswing; he has fielded phone calls and e-mail messages from ED medical directors in five states who are interested in establishing a similar project in their practice settings.

Some patients have complained about the initiative, Dr. Meyer admitted. "But on the whole, it looks like more of them are creating pain management contracts with their personal physicians."

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