A 52-year-old woman comes to the emergency department on a Saturday night with severe low back pain. She is very angry because she called her physician's office multiple times before finally reaching the covering physician, who directed her to go to the emergency department. She has had low back pain for many years, and her physician usually prescribes oxycodone. The patient's pain is much worse, and she is unable to sleep at all. She wants the emergency physician to prescribe something stronger so she can sleep through the night. The patient says, "Now that I took all the trouble to come to the emergency department, I better get some relief!" The physician has no records available at the time, but she does not appear to be drug-seeking based on the history. Which of the following is the most appropriate reaction to the patient's request?

Question

A 52-year-old woman comes to the emergency department on a Saturday night with severe low back pain.  She is very angry because she called her physician's office multiple times before finally reaching the covering physician, who directed her to go to the emergency department.  She has had low back pain for many years, and her physician usually prescribes oxycodone.  The patient's pain is much worse, and she is unable to sleep at all.  She wants the emergency physician to prescribe something stronger so she can sleep through the night.  The patient says, "Now that I took all the trouble to come to the emergency department, I better get some relief!"  The physician has no records available at the time, but she does not appear to be drug-seeking based on the history.  Which of the following is the most appropriate reaction to the patient's request?

Quizplus · Accepted Answer

Explanation: Chronic low back pain and request for narcotic medication are common problems encountered in the emergency setting. It is not unusual to see patients being treated with long-term narcotic analgesics. The primary goal and challenge in the management of such patients is to evaluate and treat the pain adequately and appropriately while avoiding drug abuse and dependency. It is often difficult to differentiate inadequate pain management from drug-seeking behavior. Patients with inadequately controlled pain are frequently irritable and demanding. It becomes even more difficult in the absence of a long-term relationship with the patient, as in this case. It is important, however, to evaluate any change in the pain character or severity and not assume that it is solely due to the patient's underlying medical condition. This patient should be asked about her current symptoms in detail and managed accordingly. (Choices A and E) Increasing the dose of her current pain medication or prescribing a more potent narcotic analgesic is not appropriate without further investigation into the cause of her worsening symptoms. (Choices B and C) The patient is in acute distress, and deferring treatment until Monday or suggesting that her pain medication request is drug-seeking is inappropriate. Her worsening pain should not automatically be assumed to be due to her chronic back pain or drug-seeking behavior. The physician should inquire about her pain complaints and perform further evaluation and treatment as indicated. Educational objective: Any change in the character or intensity of pain in a patient with chronic pain syndrome should be thoroughly investigated. The primary goal of the emergency physician is to evaluate for potentially dangerous causes that, if not identified, could result in significant morbidity and mortality. References: An evidence-based approach to the evaluation and treatment of low back pain in the emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/24044786) Pain management: association with patient satisfaction among emergency department patients. (http://www.ncbi.nlm.nih.gov/pubmed/23849365) The emergency department evaluation, management, and treatment of back pain. (http://www.ncbi.nlm.nih.gov/pubmed/20971393)

A 52-Year-Old Woman Comes to the Emergency Department on a Saturday