Svenson James E, Meyer Thomas D
Section of Emergency Medicine, University of Wisconsin, Madison, WI 53792, USA.
Am J Emerg Med. 2007 May;25(4):445-9. doi: 10.1016/j.ajem.2006.09.018.
Emergency department (ED) overcrowding is a growing problem. Frequent visits for chronic pain are a significant subset of patients. The use of narcotics in these patients is controversial. The purpose of this study was to test a strict nonnarcotic protocol in reducing need for and number of ED visits for chronic pain while at the same time addressing their pain.
This was a prospective observational study. We identified patients with more than 10 ED visits for exacerbations of chronic nonmalignant pain in the last 12 calendar months. Each patient and their physician were sent letters informing them of the concern of frequent ED use and the use of opioids for rescue therapy. Furthermore, the patient would receive medications other than narcotics in subsequent ED visits, and follow-up with the primary physician for alternatives was encouraged. Use of the ED for pain-related visits was then monitored for the subsequent 12-month period. Clinic use and outpatient medication uses were also monitored.
Fifteen patients were identified for the initial study. These patients averaged 19 ED visits per 12 months for pain-related complaints. All of them had a regular physician. After notification of the new protocol, ED visits decreased to an average of 2 visits per year. Visits with primary care physicians also dropped from an average of 19 visits per year to 7 visits. There were 7 patients who had been weaned off narcotic medications, 4 who had been converted to methadone maintenance, and 1 who had been switched to a fentanyl patch.
Initiation of a strict nonnarcotic protocol for treatment of patients with frequent ED visits for chronic nonmalignant pain results in a significant drop in the number of pain-related visits to the ED. These visits were not offset by a significant elevation in the number of clinic visits for pain complaints, and many were weaned off narcotics. Nonnarcotic protocols for acute exacerbations of chronic nonmalignant pain may be a viable alternative for reducing frequent pain-related ED visits in a select population.
急诊科过度拥挤是一个日益严重的问题。因慢性疼痛频繁就诊的患者是其中相当大的一部分。在这些患者中使用麻醉药品存在争议。本研究的目的是测试一种严格的非麻醉药品方案，以减少慢性疼痛患者对急诊科就诊的需求和次数，同时缓解他们的疼痛。
这是一项前瞻性观察研究。我们确定了在过去12个日历月内因慢性非恶性疼痛加重而到急诊科就诊超过10次的患者。向每位患者及其医生发送信件，告知他们频繁前往急诊科就诊以及使用阿片类药物进行急救治疗的问题。此外，患者在后续急诊科就诊时将接受非麻醉药品治疗，并鼓励其与初级医生跟进寻找替代治疗方法。随后对接下来12个月内因疼痛相关原因前往急诊科就诊的情况进行监测。同时也监测门诊就诊情况和门诊用药情况。
最初的研究确定了15名患者。这些患者因疼痛相关主诉平均每12个月到急诊科就诊19次。他们都有一名固定的医生。在告知新方案后，急诊科就诊次数降至平均每年2次。与初级保健医生的就诊次数也从平均每年19次降至7次。有7名患者已停用麻醉药品，4名患者已转为美沙酮维持治疗，1名患者已改用芬太尼透皮贴剂。
对因慢性非恶性疼痛频繁到急诊科就诊的患者启动严格的非麻醉药品治疗方案，可使与疼痛相关的急诊科就诊次数显著下降。这些就诊次数并未因疼痛相关门诊就诊次数的显著增加而抵消，而且许多患者已停用麻醉药品。对于慢性非恶性疼痛急性加重的非麻醉药品治疗方案，可能是减少特定人群中与疼痛相关的频繁急诊科就诊的一种可行替代方法。
