I'm an ER Doc with Pain: September 24, 2016



  • I really like the idea of co-creating a flare-up plan with one's GP. During acute/remitting pain "attacks" our minds and bodies seem to shift into crisis mode. During such times, rational and logical thinking can sometimes be a little "off", so having a pre-planned course of action to follow, can also help to reduce anxiety that frequently accompanies a crisis situation. Is there a sort of template available for people to take with them when seeing their doctors? This may help guide physicians who perhaps are less than chronic pain savvy. Thank you Dr. Huber for sharing your time and knowledge.



  • I just want to say thank you to the people who sent in questions today. They were all very good questions and with most things like this, it triggers more questions - even when some are answered, there are always more to be asked. I also want to thank the staff at Pain BC for giving me the opportunity to help participate in this important discussion. Thanks again.



  • @Forum_Moderator said:

    [QUESTION FROM FACEBOOK] Can an ER doctor refer a patient to a specialist? In the absence of a supportive physician with chronic back/neck pain and auto immune disease (Menieres) I struggle as I cannot stomach prescriptions. My visits to the ER have resulted in "see a family dr to discuss your options". She can’t help me. She told me she doesn’t know any specialists to help. I work full time (because I have to) and am raising a family. Where can the ER direct you for support?

    Yes and no. An ER doc can connect you to a specialist but the official referral for billing purposes needs to come from the family doctor’s office. If you end up in the ED with an acute vertigo attack for your menieres and it becomes apparent that you haven’t seen anyone in the ENT field and are having frequent attacks that bring you to the ED , then it is common practise for the ER Dr to connect you up...I know I did but can’t speak for all of my colleagues. I would not suggest you go to the ER for the specific purpose of getting a referral. They should help you out if it is becoming a frequent problem resulting in ER visits. I know the Unit Clerks didn’t like me because I did this a lot. If your Family Dr really is out of options and doesn’t have any suggestions then it’s time to begin the very difficult task of finding a new Dr., I'm afraid. And I know how hard that can be.



  • @Drahuber I sent that before I was finished typing because I couldn't see the bottom of the 'compose' window. In saying the doctors don't want to address it, I mean that they're still trying to pretend the silicone is of no consequence health wise, and either don't actually understand that it's causing acute pain or they don't want to look at that, I was told by a local surgeon that he didn't want to be involved. So I feel like I'm on my own medically .. and I'm in acute pain 24/7.



  • @Forum_Moderator said:

    [QUESTION FROM FACEBOOK] My question: with the use of Pharma Net, isn't it plain to see, for the ER staff, that the legitimate pain patient presenting to the ER with an acute-on-chronic exacerbation of pain, does not have drug use patterns consistent with drug abusers? Therefore, what would be a physician's reluctance to prescribe their usually-prescribed narcotics in the ER (enough to get them back to baseline, and then enough to tide them over until they can get to their own doctor)? I worked as an ER nurse for almost 20 years, and there is, generally speaking, a definite stigma against chronic pain patients. Secondly, if a patient such as this is not treated appropriately for pain, and therefore remains in severe pain, can the patient legally choose to STAY in the ER "against medical advice" until a more understanding physician can see the patient (as opposed to the patient having to go home in severe pain)? I've seen far too many people sent home in excruciating pain with inadequate prescriptions for pain meds: i.e. acute herniated discs, or other "invisible" pains. Thank you :)

    Great question. First one: the answer is yes, with PharmaNet, the ER Dr can see if the patient is Dr shopping and has multiple prescriptions. This goes a long way in sorting out who is abusing and helps a lot. I agree about the stigma and it has to do with a personality stereotype. My suggestions in earlier q's addresses this.

    Second part about giving opioids to tide patients over until they can see their physician was what I did while in practice and what most ERs docs will do. But this certainly isn’t the habit of all ER doctors. My suggestions about having a plan etc. earlier in the Q's makes this kind of help more likely. I will say, however, there is a worrying trend amongst ERs to have a blanket "no opioids" policy...there is much controversy and discussion about this within ER circles and all I can say right now is that will depend on the Dr you end up seeing. The pre PharmaNet concern about abusers and diverters and now the overdose crisis really has charged this topic and there is going to be inconsistency until it is sorted out.

    As for staying in the ED legally against medical advice, there is no mechanism for this but hopefully it should never get to that degree of desperation but in my years on ER work I know it can. Right now there is increasing evidence that opioids are not the best treatment for chronic pain and this is translating into Drs reluctance to use them in a chronic pain patient. I used to use them to tide patients over until they can see their own Dr if they need them but not all my colleagues agree with me.

    On a more positive note, I can reassure you ER docs really do want to be good at treating all kinds of pain and there is all kinds of education and innovation in this area that has happened over the last few years. If you come in and need a shoulder reduction, abcess drained or are in a major accident you will see huge changes to the chronic pain world.



  • @Forum_Moderator said:

    [QUESTION FROM FACEBOOK] I'm a bit late, cuz I just saw this...but I have 4 compressed discs in my lower back, and I'm in constant pain. What can I do and how long can I live on T3s?

    I'm not really the right person to answer this as I am not your Dr. This Q and A is about the ER. Your question is important and should be directed to your Dr.



  • @Drahuber thank you.
    I have not read that one yet but will get it now,thanks.Explain Pain,When the Body Says No and Painful Yarns are a few I have read.Luckily,I have had tremendous help with amazing people and I am forever trying to pack my toolbox with more weapons against chronic pain.
    I realized this summer after ending up in emergency from a pain specialist quadroupling my opiod type dose that I needed to fight this head on because it wasn't going to change unless I changed how I maintained and managed my pain experience.
    It's a huge learning curve and I hope we find more answers sooner than not.
    Thanks again for your time



  • @Forum_Moderator [QUESTION FROM FACEBOOK] How can a person with undiagnosed (yet chronic and severe) pain get the help they need at the ER? Because I don't yet have a diagnosis I am often treated like my pain is NOT real and that I am simply there to get my hands on pain meds. How can I get an ER doc to understand my situation even though I am not as easily "categorized" as other patients? How can I help them acknowledge that my pain is very real and needs as much help as other patients' problems? Would love some insights on this while I sit on the waiting list to get into see a pain specialist.

    Yes it is difficult and often hit and miss in getting staff that can take the time to sit down and try to understand. I think at the start you should not try to do this at the ER. While you are waiting for the Pain Specialist, make up a flare-up plan with your family Dr and if you really have to go to the ER bring it with you. The ER is not the place to expect a Chronic Pain diagnosis. If you really do end up having to go, then do the things I have mentioned in earlier questions. Certainly trying not to go when things are predictably crazy is a start...avoid evenings, for example—especially on long weekends!



  • @Forum_Moderator said: [QUESTION FROM FACEBOOK] It was at the ER that I was humiliated and told by a nurse: if you think you are coming here to get your morphone you can forget it - it won't happen". I had a very good Dr. tell me to come to his clinic but only if i was willing to work with him to completely get OFF of all the morphone. I am continuing to see him, and I have cut back quite a bit, but the pain became unbearable so he did up the long acting one again....but only if I agree to totally get off all of it eventually. What will be done to help me with my pain - I am allergic to all the other alternative pain meds! THAT is my question for the DR.

    I'll answer this with my patient hat on. Well, I’m actually in a very similar situation and feel I have run out of options too. I’m not able to practise because of my pain so it has had major impact on my life. It is very difficult to admit that medicine just doesn’t have all the answers. I am at the stage where I don’t think there are any treatments left for me and now I am trying my best to find ways to increase my coping ability. I’m sure you know all of these techniques, if not, they are in the Pain Toolbox.

    I’m not a pain DR and I don’t know what you've tried, but I will say it may be worth exploring non-medicine solutions, E.g. in neuropathic pain there are surgical, ultrasound ablative and neuromodulation options...ask your family doctor about these...most of them are known to Pain Specialists...it’s a long road and I'm on it too...I wish you all the best whilst on it.



  • @Forum_Moderator said: [QUESTION FROM FACEBOOK] My question would be why do street junkies get help with meds and drugs and I am a senior with arthritis everywhere and no Dr will give me a normal amount to ease my pain?? BC physicians have told all Drs to stop prescribing all narcotics... even in mild prescriptions.

    Good question. Well junkies get help hopefully for their addiction problem. Your problem is different but important too. I can’t speak for your Dr but the narcotic guidelines are only guidelines, not a hard and fast rule they have to follow. They are trying to prevent a whole slew of overdose deaths in normal people like you and me. There certainly is good evidence that long-term narcotic use is associated with bad outcomes. However each case is to be treated on its own merit, and most Drs know that there are certain patients where small dose long-term use seems to be helpful. There are also lots of other options for arthritis as I'm sure you know well. If your Dr doesnt agree with that, then you should seek another opinion. I realise this isn’t easy but we patients have to be our own advocates and go chase our solutions.



  • @Drahuber What would you suggest when a patient is receiving poor care because they're considered a medical liability? I haven't in the slightest presented as a threat, but the mere fact that I had defective devices in me (badly ruptured breast implants .. silicone has migrated deeply within my chest wall and is in my lymph system .. and a lot of other places). I have acute pain from it and I feel intuitively that the pain is actually not just from acute inflammation, but that there's something more going on. Doctors locally missed 16 years of symptoms that I presented with saying breast implants couldn't possibly be causing the issues (they were!). And now I'm treated like nobody wants to address it.



  • @Forum_Moderator [QUESTION FROM FACEBOOK] I live with chronic pain. I have Trigeminal Neuralgia (the suicide disease) which is the most painful pain known to man and if I go to the ER in a high pain cycle I am sent home after being treated like a drug seeker, and getting no help just to be made to feel even worse. I have been told to never return to the ER for this problem because the ER is not there to treat chronic pain. Now my narcotics are going to be taken away because there is no proof they help chronic pain. What am I to do when this happens?

    Well I’m sorry to hear of your struggles with Trigeminal Neuralgia (TN). I have something very similar in my leg. Well first of all, about being treated as a drug seeker...have a look at my suggestions in an earlier question that talks about that. It will be a bit hit and miss at the hospital depending on how busy they are and the Dr and staff you get unfortunately in terms of their receptiveness to chronic pain issues..but TN is a recognized disease that is well-known. So I think the key for you is having a flare-up plan with your Family Dr. If that plan might mean occasional ER visits then your Dr and you need to communicate with the ER manager about agreeing on a care plan when you come to the ED. One of the problems is that there isn’t much that works for TN, so some of the attitude you are getting from the ER staff might reflect this. Follow my suggestions and you might find you get a different reception.

    As for the statement that ERs don’t treat chronic pain, that is just not correct. They certainly will see and assess you. They may not agree with you on treatment options. If they refuse to assess you then that is grounds for feedback to the ER administrator. They sometimes have trouble understanding that acute chronic flare-ups happen with chronic pain like many other chronic diseases! Just this week Pain BC and the Dept of Emerg medicine for BC have done a webinar by a Emergency Dr who is also a pain expert to educate ER staff about how chronic pain is just like any other chronic disease. It’s not a place to diagnose chronic pain syndromes or manage them on an ongoing basis, but certainly there is a role for bad flare-ups. As for narcotics, I don’t know where that is going to go, but I can tell you there is a lot of push back from Chronic Pain groups and indeed Pain BC about making sure the guidelines reflect that there are stable pain patients who rely on opiates on a long-term basis to function.



  • @Drahuber THANK YOU so much for doing this!



  • [QUESTION FROM FACEBOOK] Can an ER doctor refer a patient to a specialist? In the absence of a supportive physician with chronic back/neck pain and auto immune disease (Menieres) I struggle as I cannot stomach prescriptions. My visits to the ER have resulted in "see a family dr to discuss your options". She can’t help me. She told me she doesn’t know any specialists to help. I work full time (because I have to) and am raising a family. Where can the ER direct you for support?



  • @bigrig This is really in the area of pain management and not in the area of emergency room chronic pain. So I will answer this with my patient hat on. Everyone with chronic pain knows they have a baseline pain level. We as patients are trying to find medications and treatments that bring this pain level down. However, we often find that we get to a plateau and cannot get it down any further. On the other side of the pain line are the things that we do to help us cope with that pain and function with it. There is unanimous agreement within pain specialist circles that the best long-term way of managing chronic pain is maximizing these coping strategies. This includes mindfulness and meditation, exercise, and CBT (Cognitive Behavioural Therapy). It is known that many patients can change the way their brain reacts to a chronic pain signal, and yes, you are right, it takes many years. I am currently exploring these options on my own pain journey. I would recommend you read a book called “The Brain that Changes Itself” by Norman Doidge, and lots of other self-management suggestions in the Pain BC Toolbox. Good luck and stay optimistic.

    I will say, when one is at the stage in their pain journey where the pain level is so high that it is dominating every aspect of your life, hearing about these types of coping strategies is very discouraging because they don’t seem to offer immediate relief. If your pain continues you will find a time in your journey where you will be receptive to these suggestions. I wish you all the best.



  • [QUESTION FROM FACEBOOK] My question: with the use of Pharma Net, isn't it plain to see, for the ER staff, that the legitimate pain patient presenting to the ER with an acute-on-chronic exacerbation of pain, does not have drug use patterns consistent with drug abusers? Therefore, what would be a physician's reluctance to prescribe their usually-prescribed narcotics in the ER (enough to get them back to baseline, and then enough to tide them over until they can get to their own doctor)? I worked as an ER nurse for almost 20 years, and there is, generally speaking, a definite stigma against chronic pain patients. Secondly, if a patient such as this is not treated appropriately for pain, and therefore remains in severe pain, can the patient legally choose to STAY in the ER "against medical advice" until a more understanding physician can see the patient (as opposed to the patient having to go home in severe pain)? I've seen far too many people sent home in excruciating pain with inadequate prescriptions for pain meds: i.e. acute herniated discs, or other "invisible" pains. Thank you :)



  • [QUESTION FROM FACEBOOK] I'm a bit late, cuz I just saw this...but I have 4 compressed discs in my lower back, and I'm in constant pain. What can I do and how long can I live on T3s?



  • @glenp This is a good example of what we’ve been talking about. You are going to get a hit and miss response on your request for a specific opioid treatment in the emergency department. When I was practicing, once I looked at your chart, I can see your pattern and have no problem giving you demerol and gravol and then letting you go home. I have no doubt that the hospital does use demerol occasionally and stocks it. If this pattern of care continues for you at the hospital, you may need to initiate a discussion with the care coordinator, either with or without your family doctor’s help. If at all possible, you should also look at what possibilities there are for getting your treatment outside the ER, and go through the steps in terms of having a flare-up plan that I have outlined in other answers.



  • @GubbyBadu Thanks, yes I have heard that also. I think what complicates things is that the opiates help his pain, very much so, but at a cost...big cost because he cant manage them..



  • [QUESTION FROM FACEBOOK] How can a person with undiagnosed (yet chronic and severe) pain get the help they need at the ER? Because I don't yet have a diagnosis I am often treated like my pain is NOT real and that I am simply there to get my hands on pain meds. How can I get an ER doc to understand my situation even though I am not as easily "categorized" as other patients? How can I help them acknowledge that my pain is very real and needs as much help as other patients' problems? Would love some insights on this while I sit on the waiting list to get into see a pain specialist.


Log in to reply