Intervention reduces chronic pain visits

Consultation of 15-30 minutes redirects patients

A simple behavioral health consultation of 15-30 minutes has helped reduce the number of chronic pain patients who use the ED at Providence Newberg Medical Center in Newberg, OR, as their primary source of medical care.

"We now have three years of data," says Mary Peterson, PhD, director of clinical training in the Graduate Department of Clinical Psychology at George Fox University, also in Newberg.

Peterson, along with several graduate students, tracked 90 high utilizers of the ED for three years. "The first year, the average number of visits per patient was 6.8. The second year it was 3.5, and the third year it was 2.3," she reports. High utilizers were patients who had had more than six visits in the previous six months or more than three visits in the previous three, she explains.

Jonathan Woodhouse, PsyD, a neuropsychology postdoctoral fellow in psychiatry and behavioral sciences at the University of Oklahoma Health Sciences Center in Norman, used this intervention for his doctoral dissertation while at George Fox. Woodhouse says, "We originally had a behavioral health consultation team embedded in the ED to address suicidal behaviors. We piggybacked on that team and developed another service."

The intervention worked like this: Grad students would meet patients at the bedside and introduce the "bio-psychosocial model," which, Woodhouse explains, is a way of validating the patient's physical pain while introducing the concept that there are other treatment options besides opioids.

"Often there is a level of resistance because patients do not want to hear that depression is the cause of their pain," says Woodhouse. "So we approach it from a position of empathy." The students explained to the patient that while anxiety and depression play a role, pain can exacerbate them and pain meds won't help.

The second part of the intervention involves explaining to the patient that while they in fact might require pain medications, the ED is not the best place to receive them. "We tell them that if they have a primary care provider, that is the best place for them," says Woodhouse. "Many people do not have one, so we were able to set up a contract with primary care providers in the community who were willing to take on these patients on a rotating basis."

When patients left the ED, they received information on chronic pain and materials on the psychological management of pain and letters saying they should go to primary care providers. These patients were tracked, and if they continued as "frequent flyers," they would get a second letter stating more strictly that they needed to go to a primary care provider and that the hospital reserved the right to not continue opioids. A third letter, if necessary, stated that they would not receive opioids at the hospital.

"This is a confounding variable and had a powerful effect," says Woodhouse.

Jeff Hanson, RN, the manager of emergency services, says, "We had a great resource in this tool, and it was strengthened when we were able to take it to adjoining clinics and follow up on the outpatient side." For many of these patients, he points out, the ED previously was their treatment venue. "When the students were able expand their reach/consultation practice and do it immediately in the ED and also have follow-up availability in clinics working in association with local primary care providers, that had a huge impact," Hanson says. (Hanson, who joined the team well into the intervention, says it was also strengthened by a new policy adopted by the ED physicians. See the story below.)

Sources

For more information on treating chronic pain, contact:

  • Jeff Hanson, RN, Manager of Emergency Services, Providence Newberg Medical Center, Newberg, OR. Phone: (503) 537-1782.
  • Mary Peterson, PhD, Director of Clinical Training, Graduate Department of Clinical Psychology, George Fox University, Newberg. E-mail: mpeterson@georgefox.edu.
  • Jonathan Woodhouse, PsyD, Neuropsychology Postdoctoral Fellow, Psychiatry and Behavioral Sciences, University of Oklahoma Health Sciences Center, Norman. Phone: (405) 271-8001, Ext. 47621. E-mail: jonathan-woodhouse@ouhsc.edu.

New policy aids program

While a behavioral health program has three years of results to show it successfully helped reduce ED visits by patients seeking painkillers, the ED manager believes it was strengthened by a new policy adopted by the physicians.

"It was up to the ED doctors and nursing staff to really buy into it and present it and use the tool that was there," says Jeff Hanson, RN, the manager of emergency services at Providence Newberg Medical Center in Newberg, OR. "Once you got everyone working together and essentially enforcing and putting into practice what was there for us to utilize, it really worked."

The program included a policy that said the ED would be Demerol-free and that it would not ever give methadone. "Our group at a prior hospital had a similar protocol, but it only had limited success because our manager would undo what we attempted," says Russ Griggs, MD, medical director of the ED. "When we came out here, since we started a new group, the four of us were all aligned."

Primary care providers, who "used to send these patients to the ED and never heard from them again," soon were bombarded with calls from their patients, says Griggs. "I ended up sitting down one on one with them to explain why it was better for them and the patient," he recalls. "We went through a rough patch, and then it got better."

Source

For more information on protocols for the use of opioids, contact:

  • Russ Griggs, MD, ED Medical Director, Providence Newberg Medical Center, Newberg, OR. Phone: (503) 544-1990.

Clinical Tip

ED staff should take holistic view of pain

When treating a patient for chronic pain, you must take into account and care for the whole patient, says Jeff Hanson, RN, the manager of emergency services at Providence Newberg Medical Center in Newberg, OR.

"Many studies have documented why patients may present to the ED for chronic pain complaints, and not all of them are truly based in pain," he says. "There are depression issues, anxiety issues, and lack of coping skills. As you get providers to look at the whole of the patient and put non-pharmaceutical treatment options in place, you're looking at reducing ED visits."