Mrs H was a 45-year-old woman being 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 injections of meperidine and hydroxyzine for breakthrough pain. The patient and her physician had a contract stating she would only take the narcotic medications that he prescribed and she would not go to the emergency department (ED) for pain medications. Mrs H had been employed as a licensed practical nurse, however, because of her condition, her license had been suspended.
Mrs H did not maintain her contract. She visited multiple EDs, requesting pain medications including meperidine and hydromorphone. If the first ED provider refused treatment with narcotics, she would go to the next local ED and demand the same medications. According to Mrs H's spouse, she also obtained narcotics illegally.
After several years, the patient and her treating physician agreed that she needed rehabilitation for her narcotic addiction, and she attended an inpatient program. Upon discharge, she relapsed and resumed her previous behavior, visiting local EDs demanding narcotic pain medications.
The staff within our ED recognized the serious nature of her condition and developed a plan to contact her treating physician at each visit. Her physician recommended that we inject 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 physician's recommendation to use a placebo, managing the patient's condition in the ED remained a challenge. The patient's aggressive behavior escalated. She threatened to harm members of the ED staff if they would not treat her with narcotic pain medications. She displayed manipulative 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 patient's behavior and frequent visits 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 narcotics due to her addiction and worsening condition and violation of contract with her neurologist.
The patient's clinical status continued to deteriorate. Her speech was slurred. She walked with a shuffling gait, and had tremors. Given her presentation, some providers refused to evaluate this patient, leaving her to be seen by another provider. The patient did not want to be treated by the advanced practice nurses because she felt they were less likely to treat her with narcotics. The advanced 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 treatment 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. According to the commission, a provider must believe a patient to be experiencing the level of pain he or she reports and to treat the pain appropriately.
The patient's behavior compelled our ED personnel to examine the ethical issues surrounding this case. The issues of pain management in the presence of addiction needed to be discussed in relation to the ethical principles of autonomy, nonmalficence, beneficence, and informed consent. The hospital's risk management team and the patient's neurologist were consulted to determine what could ethically and legally be done for this patient 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 management and the ED staff reached an agreement. The following actions were taken. A certified letter was sent to the patient advising her that ED personnel would no longer treat her migraines with narcotic medications. She would be evaluated and treated with the nonnarcotic headache medications recommended by her neurologist. This decision was based on the premise that emergency care is episodic in nature and treatment of her condition required specialized management 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.
DISCUSSION OF CONTEXT AND ETHICAL PRINCIPLES
Drug-Seeking Behavior for Pain Management
Pain is the most common presenting complaint to a physician's 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 nonmalignant etiology (Vukmir, 2004). Chronic, nonmalignant pain accounts for 10% to 16% of outpatient visits and 25% to 40% of hospitalizations (Weaver & Schnoll, 2002).
Pain drives drug seeking for opioids in both animals and humans. This causes increased drug-seeking behaviors and cravings in patients with substance use disorders (Trafton, Oliva, Horst, Minkel, & Humphreys, 2004). Pain is often associated with mental health problems and functional and social disability. Patients in pain have increased rates of depression, anxiety, suicidal ideation, and hallucinations. Depression rates increase with increasing rates of pain (Trafton et al., 2004). Problematic behaviors such as health complaints, decreased physical function, illicit drug use, mood disorders, healthcare utilization, 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 increase if pain is not adequately controlled. To avoid pseudoaddiction, providers must believe patient complaints are legitimate. Initially, it is nearly impossible to distinguish between 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 addiction and pseudoaddiction (Weaver & Schnoll, 2002).
Patients' demanding behavior to obtain medications can cause them to claim an allergy to nonaddictive medications, report a high tolerance to drugs, may "lose" a narcotic prescription, or claim to "run out early." Doctor shopping is another common drug-seeking behavior where the patient sees multiple 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 requests, 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 from additional 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 patients with substance use disorder to control their illicit substance use (Trafton et al., 2004). Dissatisfaction with pain management is more likely with more severe pain, as well as higher rates of depression, anxiety, and altered mental status (Vukmir, 2004). Pain management is difficult because it relies on subjective 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 management resources, particularly for populations served by the ED, pseudoaddiction is the most likely cause for a large proportion of drug-related behaviors deemed aberrant. Patient reports of distress associated with unrelieved symptoms, aggressive complaining about the need for higher doses, and patient dose escalation are signs of pseudoaddiction. The hallmark of pseudoaddiction is that aberrant behaviors disappear when adequate analgesics are given to control pain (Todd, 2005). Table 2 illustrates behaviors more or less consistent with addiction.
Autonomy
Personal autonomy is defined as self-rule that is free from both controlling interference by others and from limitations such as inadequate understanding that prevents meaningful choice (Beauchamp & Childress, 2001). Autonomous persons with self-governing capacities sometimes fail to govern themselves in particular choices because of temporary constraints caused by illness or depression or because of ignorance, coercion, or other conditions 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 autonomous, 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 disabled as a result. She was unable to be an active participant in her care due to her desire to reach her goal of obtaining her drug of choice. It is reasonable to question whether treating this patient in the ED also contributed to her drug-seeking behavior and addiction. Some providers who would treat her with increasing doses of narcotics reinforced the patient's behaviors. In addition, those who would not treat her and put her into withdrawal may have increased her pain.
Nonmalficence and Beneficence
The concept of nonmalficence can be defined as the obligation to intentionally do no harm, whereas beneficence can be defined as the obligation to promote or do good (Beauchamp & Childress, 2001). Generally, healthcare providers are caring individuals attempting to keep their patients from receiving harmful treatments while providing beneficial care to their patients.
In Mrs H's case, it was difficult to determine which treatment would deliver the greatest benefit without causing harm. Some providers felt that treating her pain would be harmful for her condition, thus worsening her drug-seeking behaviors. Other caregivers felt that providing narcotic pain treatment in the acute arena would be the only reasonable choice. She would receive temporary pain relief and avoid withdrawal symptoms. The question in this patient's management was whether the healthcare providers caused her harm by treating her with narcotics, a contributing factor to her present-day addictive behaviors. Obviously, the outcome 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 benefit the patient by offering pain relief. Over time, what was once a beneficial treatment became a detriment.
Informed Consent
When initiating the prescription for narcotic 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 individual's autonomous authorization of a medical intervention (Beauchamp & Childress, 2001). Informed consent is obtained in some context 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 often under the influence of a variety of substances. 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 alcohol and drug problems. However, some ED providers receive limited training in recognition 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 deserve (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 rationality. Aberrant drug-related behaviors as the term suggests is a broad range of behaviors 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 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 personal 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 developed while promoting quality to achieve these goals (Todd, 2005).
REFERENCES