Pathway for Patient with Chronic Pain Complaint
Brief Chart Review
&
Medical Screening Exam
Aberrant drug-seeking
behavior
(using false or misleading
tactics to obtain opioids
or other controlled
substances for nonmedical use, ie misuse,
abuse or drug diversion)
1
FH medical record including checking for care plan
Review Care Everywhere for visit history
Prescription Drug Monitoring Program (PDMP)
Acute Pain
(Urgent Medical
Problem)
Chronic Pain (includes acute exacerbation
of chronic pain and repeat visits for various
pain complaints)
Yes
Cancer
Yes
Out of Chronic
Pain Pathway
No
Sickle
Yes
Sickle Cell
Pathway
No
Yes
Case Management to flag
chart
SW intervention for AODA
resources
ED INTERVENTIONS:
Non-pharmacological mgmt: ice/heat, elevation
Pharmacological mgmt: NSAIDs, anxiolytics, antiemetics, pyridium, etc
Discourage IM, IV opioids
Symptomatic care for active opioid withdrawal with clonidine and
dicyclomine
Consider PO opioids
Strongly encourage PO Benadryl over IV Benadryl
*Scripting may be used here (see following page)
POST ED CARE:
PMD / Pain Management
Case Management to
arrange close follow-up
Yes
Adhere to pain contracts
Contact out-patient provider
PRESCRIPTION WRITING:
No replacement prescriptions for lost, stolen,
forgotten, ran out, PMD or pain doc not reachable.
For patients in pain contracts, no RX unless discussed
with outpatient Provider
 Short course opioid standard < 15 tabs hydrocodone
*Scripting Strategies for Drug-Seekers & Superusers (Studer Group)













Patients exhibiting inappropriate drug-seeking behavior who have NOT frequented the ED
“It is important that we discover the cause of your pain rather than just treat it. Once I understand what
is causing your pain, I can give you something that can help reduce it.”
“For this condition, I usually prescribe (insert non-opioid medication name).”
“Usually it is not possible to completely eliminate your pain, so our goal today is to reduce it to a more
tolerable level.”
“I acknowledge that you are having pain from (condition). A prescription for (NSAID) can benefit you, as
it can decrease the inflammation that is causing your pain and make you feel better.”
“I’m sorry, but I will not prescribe some of the other medications we have already talked about.”
Patients exhibiting inappropriate drug-seeking behavior who HAVE frequented the ED
“In looking over your medical records, I see you have visited us (+/- other EDs/urgent care facilities)
various times over the past (days, weeks, months).”
“It looks like you have received a number of prescriptions for (controlled substance[s]) at these visits
from a number of different doctors, which concerns me.”
“I want to help you today, but I do not feel comfortable treating you with (class of medication). I want
to make you feel better and can offer you a number of different treatment options, but none of them
will involve giving you (class of medication).”
“Let’s agree that after today, you will make every effort to see you own doctor for any follow-up,
because your visits have become so frequent that our doctors will no longer be prescribing you opioids
(or other class of medication) for you.”
“We believe in having you work with a single physician to create long-term strategy for managing your
condition, which often involves other treatment options for your pain besides chronic opioid use.”
Chronic pain patient that has a pain contract on file who presents for treatment of their chronic pain
and has not followed the guidelines stipulated in the pain contract (for example, not following up,
seeking opioid prescriptions from provides other than his/her pain doctor)
“I want to help you feel better today.”
“Our policy requires doctors to follow pain contracts all the time, and therefore I cannot give you your
usual medication, but we can try some other things that may make you feel better.”
“To make sure your concerns are addressed, I will notify your doctor that you came in today so that
he/she can discuss further care options.”