How Emergency Departments Fail Pain Patients in Need

2 months

Since 2000, Anne Fuqua has been on opioid pain medications, including fentanyl and Oxycontin, notorious for their involvement in different waves of the overdose crisis. She has never experienced problematic use and believes she “wouldn’t be here” if she hadn’t had access. Fuqua, who lives in Birmingham, Alabama, has personally and through research known many chronic pain patients who’ve taken their own lives because of turbulent access to medication, she told Filter.

But in 2015, just before the government kicked the US government kicked its overdose-crisis response into high gear, her prescribing physician closed his practice. Fuqua struggled but found a new physician. Then a year later in 2016, she ended up going to the emergency room because a kidney stone and resulting infection triggered autonomic dysreflexia leading to what she felt was dangerously what she felt was dangerously-high blood pressure.

Fuqua went to the emergency room because she was concerned about her blood pressure. She wasn’t expecting much in the way of pain relief because she knew EDs were hesitant to prescribe opioids to any patient, but were particularly reluctant to use opioids in patients already taking them for chronic pain – even though current guidelines recognize opioids may be needed for instances of acute pain like kidney stones or fractures. The emergency doctor was more concerned about something else. “If you are taking this medication [Oxycontin and a fentanyl patch], you have a problem. Your problem isn’t a kidney stone,” she recalled the doctor saying. The nurse had added, “Well I can tell you this: We’re not giving you anything for pain.”

“I was just stunned that they could treat somebody like that,” said Fuqua. “It was humiliating.”

Now an advocate for pain patients, Fuqua knows she’s one of many who have experienced this denial of care by an emergency department in the name of preventing opioid use disorders and overdoses. Between 2010 and 2011, the rising number of opioids prescribed in emergency departments began to pivot downwards, found a January 8 study by the Centers for Disease Control and Prevention (CDC). The study authors attributed the declines, in part, to government programs dedicated to changing opioid prescribing practices and prescription drug monitoring programs.

Researchers and the CDC alike affirm that pain patients have been obstructed from accessing proper medications by misapplied guidelines. In 2016, just before Fuqua says she went to the ED, the CDC released the Guideline for Prescribing Opioids for Chronic Pain, which has been credited by a June 2019 New England Journal of Medicine article, and affirmed by the CDC, for intensifying the clampdown on prescribing.

The following year, the American College of Emergency Physicians published its own guidelines recommending that “Patients presenting to the ED for acute exacerbation of chronic pain should generally not receive an opioid analgesic or opioid prescription.” They do recognize that patients with chronic pain on opioids may require additional opioids in the ED for acute pain like a fracture or kidney stone that’s unrelated to their chronic pain.

Prescription drug monitoring programs (PDMP) may also have a chilling effect on ED prescribing patterns, suggests the CDC study. PDMPs, most of which have been founded in the past decade, allow physicians to see all of the patient’s prescriptions and their corresponding prescribers. They can function as a “tool of refusal,” Liz Chiarello, a medical sociologist at St. Louis University who interviews pharmacists and physicians for her research on PDMPs, told Filter for an April 2019 report. By that, she means that a doctor may decline to prescribe an opioid for pain purposes simply because of the number of existing prescriptions held by the patients, which is flagged as a risk factor, and by extension, a liability. This dynamic has been described by public health researcher Leo Beletsky as being “essentially blacklisted from receiving healthcare.”

Emergency rooms are designed to be last resorts for people experiencing acute health issues, but patients like Fuqua have repeatedly faced lapses in care for pressing pain crises because of the medical community’s collective anxiety around prescribing opioids.

Updated January 9, 2020: Elements of Fuqua’s story were misdescribed in the previous version of this article and have since been corrected.

Photo of an emergency department building in Alaska, by Wonderlane via Wikimedia Commons/Creative Commons.

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