Pain Medicine 2015; 16: 1759–1763 Wiley Periodicals, Inc.

Brief Research Report Chronic Pain Patients’ Impressions of an Emergency Department Opioid Prescribing Guideline Poster

*Division of Health Policy Translation, Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA; †Tufts University School of Medicine, Boston, MA; ‡Craniofacial Pain Center, Tufts University School of Dental Medicine, Boston, MA

were surveyed with a close-ended, structured questionnaire. Included patients were aged 18 and older with pain lasting 12 weeks or longer. Patients were shown a sample pain poster. The primary outcome was determination if such a poster would prevent the patient from staying to receive care in the ED.

Funding sources: No grant or other financial support was obtained for this study.

Results. One hundred patients were surveyed. Most patients (77%) reported having been a patient in the ED in the past, and of these, 23% reported visiting the ED for worsening of chronic pain. After being shown the poster, 97% believed the recommendations in the poster were reasonable and 97% thought that the poster should be displayed in the ED. Seven patients (7%) reported that seeing the poster in the ED waiting room or triage area would intimidate them, and two patients within this group (2% of total sample) reported that it would prevent them from staying to get care.

Author contributions: SGW conceived the study and designed the trial. SGW and CL supervised the conduct of the trial and data collection. PFY undertook recruitment of subjects and gathered data. SGW analyzed the data. SGW drafted the manuscript, and PFY and CL contributed substantially to its revision. SGW takes responsibility for the paper as a whole.

Conclusions. The vast majority of patients with chronic pain in this cohort believes that a pain guideline poster is reasonable and should be posted in the ED. However, a small percentage of patients reported that they would feel intimidated by such a poster and that it would prevent them from staying to get care, a result meant to inform hospitals and policy-makers deciding if such posters should be displayed.

Reprint requests to: Scott G. Weiner, MD, MPH, Division of Health Policy Translation, Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis Street, Neville House, Boston, MA 02115, USA. Tel: 617-732-5640; Fax: 617-264-6848; E-mail: [email protected].

Conflict of interest: The authors all declare no potential conflict of interest.

Key Words. Opioids; Prescriptions Introduction

Abstract Objective. To determine if an opioid prescribing guideline poster, meant to be posted in an emergency department (ED) triage area, would deter patients with chronic pain from seeking care. Methods. We prospectively enrolled patients presenting to a chronic craniofacial pain clinic affiliated with an urban academic Level I trauma center. Patients

The United States is in the midst of an epidemic of prescription drug overdose deaths [1]. As a result, many communities have taken measures to curb inappropriate prescribing of opioid pain medications. One such measure is the creation of guidelines that can be used in emergency departments (EDs) and accompanying posters to inform patients of the initiative [2–4]. Although practice guidelines are encouraged, the use of posters meant to be placed in waiting rooms, triage

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Scott G. Weiner, MD, MPH,* Paul F. Yannopoulos, BA,† and Chao Lu, DDS‡

Weiner et al. areas or treatment rooms has recently come under scrutiny by the Centers for Medicare and Medicaid Services (CMS) as they may lead to violations of the federal Emergency Medical Treatment and Active Labor Act (EMTALA) statute that mandates EDs to perform a medical screening exam on every patient that presents to the ED for care to exclude an active emergency medical condition (Appendices 1 and 2).

This study aims to determine patient impressions about a prescribing guideline poster. The target population is patients with chronic pain, so the study was conducted in a pain clinic. The primary outcome was determination if a patient reported that such a poster would prevent them from staying to receive care in the ED. Secondary outcomes were to determine if patients thought the recommendations were reasonable, if they should be hung in the ED waiting room or triage area, and if they were intimidating to patients with chronic pain.

We aimed for 100 patients enrolled. Our primary endpoint is the answer to the question: “If you saw this poster in the Emergency Department waiting room or triage area, would it prevent you from staying to get care?” As we are unaware of preliminary data, we hypothesized that five of 100 patients will answer “yes” to this question, yielding a percentage of 95% (95% CI 88.8–97.8%) answering “no”. Data Analysis

Materials and Methods Study Setting and Section of Participants This was a cross-sectional convenience sample of adult patients with chronic pain presenting to the hospital’s Craniofacial Pain Center, devoted to treatment of patients with chronic headache and facial pain. We chose to administer the study in a pain clinic to efficiently sample a large number of patients that specifically suffered from chronic pain. The hospital is an urban, academic Level 1 adult and pediatric trauma center, with an annual ED patient volume of approximately 42,000 visits. The hospital is physically adjoined to the university’s dental school, where this pain clinic is located. Participants were identified by one of the study authors (P.F.Y.) while they were in the clinic’s waiting room. This researcher was present on days the clinic was open and approached every available waiting patient. Excluded patients were those who refused to participate, were in obvious distress, had absence of a chronic pain syndrome (specifically defined to patients as any pain lasting more than 12 weeks), or who did not speak English. There was no compensation for participation in the study. The protocol was approved by the Institutional Review Board.

Results were recorded on paper and transcribed to a computerized spreadsheet. A second investigator double-checked the data entry to ensure accuracy of transcription. Data was analyzed in descriptive fashion using JMP 8.0 (SAS Institute, Cary, NC). Results

Study Protocol

One hundred twenty-eight patients were approached for enrollment between May and July, 2014. Twenty-five patients were excluded as they did not have chronic pain, and three patients declined participation, leaving 100/103 (97.1%) of eligible patients responding. Every approached patient spoke English. Mean age was 54.3 (SD 13.8) years. 79.0% (n 5 79) of respondents were female. White race was most common, 91.0% (n 5 91), followed by “other” (n 5 6) and black (n 5 3). Five patients identified a Latino ethnicity. Education was distributed as follows: 57.0% (n 5 57) completed college and 31.0% (n 5 31) completed graduate school; 10.0% (n 5 10) completed up to high school and 2.0% (n 5 2) had not completed high school. Primary insurance was 68.0% (n 5 68) private insurance, 26.0% (n 5 26) Medicare, 2.0% (n 5 2) Medicaid, 4.0% (n 5 4) other or unknown. In the total cohort, 94.0% (n 5 94) reported having a primary care physician that they had seen in the previous 6 months.

The survey tool was comprised of 17 closed-format questions and consisted of three parts (Appendix 3). The

Every patient enrolled in the study (n 5 100) had chronic pain lasting more than 12 weeks. The median of

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Policy-makers and hospitals need guidance about guidelines and their associated posters. It is important for patients to have realistic expectations about their care in the ED and these initiatives support clinicians who are struggling to provide adequate pain control but avoid exacerbating the problem of medication abuse and overdose. Currently, only opinion exists about the effect such posters would have on patients but there is no objective evidence to make an informed decision about hanging such posters in clinical areas.

survey was designed by a consensus panel of three pain physicians, two emergency physicians and a nonphysician. The instrument was not tested or validated prior to the study. Part I assessed the patient’s history of chronic pain and prior use of the ED. For Part II, patients were shown the Massachusetts College of Emergency Physicians (MACEP) ED pain poster (Figure 1). This poster was codesigned by one of this study’s authors and mirrors that which was created and in use in New York City during the study period. Permission was obtained from New York City Health and Human Services to create the poster, and from MACEP to use their poster for this study. Patients were asked their impressions about the poster. It also asked if the poster would intimidate the patient or prevent them from staying for care in the ED. We did not define the word “intimidate” and left that to the interpretation of the patient. Part III ascertained demographic information about the respondents. The results were kept separate from the medical record and were not shared with the treating clinicians.

Impressions of a Prescribing Guideline Poster

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Figure 1 The Massachusetts College of Emergency Physicians emergency department pain poster. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary. com.] reported average discomfort over the past seven days (on a scale of 0 to 10) was 5 (interquartile range 3.5– 7.0). A minority (16.0%, n 5 16) reported taking opioid medications for chronic pain. Most patients (77.0%, n 5 77) reported having been a patient in the ED in the past, and of these, 23.3% (n 5 18) reported coming to the ED for a worsening of chronic pain. No patient reported coming to the ED for a refill of pain medication. After being shown the poster (Figure 1), 97.0% (n 5 97) believed the recommendations in the poster were reasonable. Also, 97.0% (n 5 96, one patient declined to answer) thought that a poster like the example shown to them should be hung in the ED. Seven patients

(7.1%, one patient declined to answer) reported that seeing the poster in the ED waiting room or triage area would intimidate them. Within this group of seven patients, two patients (2.0% of total sample) reported that if they saw the poster in the ED waiting room or triage area, it would prevent them from staying to get care. Both of those patients were in the group that had reported coming to the ED in the past for an acute exacerbation of chronic pain. Discussion Death from prescription medication overdose has reached epidemic proportions in the United States [1]. 1761

Weiner et al. Communities are struggling to determine solutions that will both provide adequate pain control to patients who are truly in need while preventing the over-prescribing that is hypothesized to lead to abuse and diversion of these medications. One potential solution is the creation of opioid prescribing guidelines. These guidelines are just one piece of the puzzle, and join multiple other interventions including implementation of prescription drug monitoring programs, tamper-proof medications and naloxone distribution, which all aim to mitigate the overdose problem.

The controversy surrounding the hanging of these posters in the ED began in early 2013. The South Carolina Hospital Association contacted their regional CMS office (Atlanta Regional Office, CMS Region 4) to obtain permission to place the posters in ED waiting rooms or ED patient examination rooms. The regional CMS office responded that EMTALA “states that the hospital must provide for an appropriate medical screening examination. To determine whether or not an emergency medicine condition exists” (Appendix 1). Severe pain, psychiatric disturbances and/or symptoms of substance abuse are included as emergency medical conditions. It was the belief of their regional CMS office that the language present in the opioid prescribing poster could be considered coercive or intimidating to patients with painful conditions, violating the language and intent of EMTALA. The regional CMS office that covers Ohio (Region 5) came to the same conclusion when asked (Appendix 2). These rulings do not represent the formal opinion of CMS on a national level, so there is a window of opportunity before a decision is made for the country. The use of posters for patients has held an important role for public health practitioners. Evidence demonstrates that patients read and understand waiting room posters [9,10]. The Centers for Disease Control and Prevention have created countless posters specifically for patients, ranging from information about methicillin resistant Staph aureus to informing the public about antibiotic stewardship and informing patients that they might not receive an antibiotic if it is not medically indicated [11,12]. Should information to patients about the dangers of opioid pain relievers and widely disseminated prescribing guidelines be treated any differently? 1762

As a final note, although we did not research this idea in our study, an alternative to hanging the posters in the waiting room or triage area would be to distribute them, in handout form, to patients after an appropriate medical screening examination. This information, when given to patients directly by their treating clinician in the form of educational material, could provide a powerful opportunity for education and counseling and would not encroach on the EMTALA legislation. Limitations This was a single center study in a particular clinical environment of patients suffering specifically with orofacial and headache pain. Most patients were female and white, which may correspond with the prevalence of orofacial pain disorders and headaches (e.g., temporomandibular joint syndrome and trigeminal neuralgia) treated in the clinic. Furthermore, most patients were privately insured and highly educated, and only about a quarter of patients in the cohort had been to the ED with exacerbation of chronic pain in the past. Therefore, it is likely that this cohort does not represent the patient population that comes to the ED seeking refills of opioid pain medications and for whom the pain posters have been created. We did not study patients who did not speak English fluently (although no approached patient was excluded for this reason), but most pain posters that we have seen are currently only written in English. We did not define the word “intimidate” for patients. We noted informally that several patients disliked the design of the poster, which could have also influenced their response. We only tested one pain guideline poster. Although the survey tool was designed by a consensus panel that included a nonphysician, it was not trialed or validated prior to the study and not evaluated for clarity or health literacy. The primary limitation of the study is that we did not actually study behaviors of patients who came to the ED with a pain complaint and saw an actual poster. Reading a poster handed to a patient and seeing one hung in a waiting room are different experiences. Given the recent regional CMS determinations, we were worried about the ethics and legality of performing this ideal study. Because of these limitations and the complex issues inherent to opioid prescribing, further study including qualitative

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Several cities and states have created guidelines that specifically target prescribing in the ED. Washington State was one of the first states to create formal guidelines [5]. Other examples are Ohio, which created the Opioids and Other Controlled Substances (OOCS) Prescribing Document, responding to a 440% increase in unintentional drug overdose from 1999 to 2011, as well as New York City and California ACEP [6–8]. Each of these entities also created posters to be hung in an ED waiting room to inform patients about the guidelines. In fact, New York City provides free posters for EDs that adopt the guidelines [4]. As of this report, 35 hospitals have adopted the guidelines, although the number of EDs that displays the poster in the ED waiting room is unknown.

Our study found that the vast majority of patients (97% in our cohort) support the guidelines and agreed that they should be hung in the ED. We were reassured by this number, which indicates that even patients with chronic pain understand that there are dangers of opioid pain medications and agree that the information should be shared. We hypothesized that 5 of 100 patients would not stay for emergency care if they saw the poster hung in the waiting room or triage area. Although only two patients actually did respond “yes” to this question, we were also surprised about those and the additional five patients who felt “intimidated” by the poster. In reality, even if a single patient would be turned away before a medical screening exam, the practice could be interpreted as leading to potential EMTALA violations.

Impressions of a Prescribing Guideline Poster interviews or focus groups may help elucidate some of the richer and complex questions surrounding this topic. Conclusions In our study, the majority of patients with chronic pain believes that a pain guideline poster is reasonable and should be posted in the ED. However, 7% of patients reported that they would feel intimidated by such a poster and 2% reported that it would prevent them from staying to get care, a result meant to inform policy-makers deciding if such posters should be displayed. Given the findings, we conclude that providing this information directly to patients in a treatment room after an appropriate medical screening exam is the safest practice.

2 Weiner SG, Perrone J, Nelson LS. Centering the pendulum: The evolution of emergency medicine opioid prescribing guidelines. Ann Emerg Med 2013;62(3):241–3. 3 Neven DE, Sabel JC, Howell DN, Carlisle RJ. The development of the Washington State emergency department opioid prescribing guidelines. J Med Toxicol 2012;8(4):353–9. 4 New York City Department of Health and Mental Hygiene Opioid Prescribing Poster for NYC Emergency Departments. Available at: http://www.nyc. gov/html/doh/downloads/pdf/basas/opioid-poster. pdf (accessed March 2015).

6 Ohio’s Opioid Prescribing Guidelines. Available at: http://www.opioidprescribing.ohio.gov/ (accessed March 2015). 7 California Chapter of the American College of Emergency Physicians Safe Prescribing Guidelines. Available at: http://californiaacep.org/public-health/safeprescribing (accessed March 2015). 8 New York City Department of Health and Mental Hygiene Opioid Prescribing Guidelines. Available at: http://www.nyc.gov/html/doh/html/hcp/drug-opioidguidelines.shtml (accessed March 2015). 9 Montazeri A, Sajadian A. Do women read poster displays on breast cancer in waiting rooms? J Public Health (Oxf) 2004;26(4):355–8. 10 Ward K, Hawthorne K. Do patients read health promotion posters in the waiting room? A study in one general practice. Br J Gen Pract 1994;44(389):58325. 11 Centers for Disease Control and Prevention General MRSA Information and Educational Resources. Available at: http://www.cdc.gov/mrsa/community/ posters/index.html (accessed March 2015). 12 Centers for Disease Control and Prevention. Get Smart: Know When Antibiotics Work Posters. Available at: http://www.cdc.gov/getsmart/campaignmaterials/posters.html (accessed March 2015).

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References 1 Centers for Disease Control and Prevention (CDC). CDC grand rounds: Prescription drug overdoses—A U.S. epidemic. MMWR Morb Mortal Wkly Rep 2012;61(1):10–3.

5 Washington Emergency Department Opioid Prescribing Guidelines. Available at: http://washingtonacep.org/Postings/edopioidabuseguidelinesfinal.pdf (accessed March 2015).

Chronic Pain Patients' Impressions of an Emergency Department Opioid Prescribing Guideline Poster.

To determine if an opioid prescribing guideline poster, meant to be posted in an emergency department (ED) triage area, would deter patients with chro...
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