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CHAPTER 38: Chronic Pain 259 Chronic Pain David M. Cline  CHRONIC PAIN EPIDEMIOLOGY Chronic pain is defined as a painful condition that lasts greater than 3 months, pain that persists beyond the reasonable time for an injury to heal, or pain that persists 1 month beyond the usual course of an acute disease. Whereas acute pain is a vital biologic signal to stop the individual from a potentially injurious activity or to pursue medical care, chronic pain serves no obvious biologic function. Complete pain relief is unrealistic in cases of chronic pain. Rather, the goal of therapy is pain reduction and return to functional status. Chronic pain syndromes dis cussed in this chapter are divided into neuropathic and nonneuropathic conditions, with a separate discussion of abdominal and pelvic pain syndromes. Aberrant drug-related behavior is also discussed. Chronic pain is a common problem, affecting 20% to as much as 50% of the population in developed countries. 1-3 Women (34%) are affected more than men (27%). 1 The back is the most common site for chronic pain, followed by the knee and neck. 1 The prevalence of neuropathic pain is 6.9% to 10% of the population. 4 The prevalence of chronic abdominal pain in association with irritable bowel syndrome and func tional dyspepsia is 23%.5 Risk factors for chronic pain include increasing age, female gender, higher body mass index, and chronic illness. 2 An exacerbation of chronic pain is part of the presentation of 11% to 15% of ED visits. 6 Compared to patients with acute pain, chronic pain patients are more likely to report their pain as severe and are more likely to be frequent visitors to the ED. PATHOPHYSIOLOGY Our understanding of the pathophysiology of chronic pain is incomplete. Many chronic pain syndromes follow nerve or tissue injury, producing nerve dysfunction secondary to the mechanical injury or in response to chemical mediators released from adjacent cell injury. Peripheral sen sitization or central sensitization commonly follows, where peripheral nerves or the CNS become abnormally sensitive, exhibiting pathologic spontaneous activity through upregulation of sodium channels and receptors. 8 Neuroplastic changes in the central descending pain modu latory systems, inhibitory or facilitatory, may lead to further hyperex citability. These changes lead to hyperalgesia (exaggerated response to a normally painful stimulus) and allodynia (pain from a normally nonpainful stimulus). In several disorders, a history of injury may be lacking, such as for fibromyalgia, where central sensitization plays a key role.9 Psychological factors frequently precede or follow the onset of chronic pain and often predispose individuals to physiologic changes through the fear-avoidance model. 10 The fear of pain may lead to disuse disability, which leads to nerve hyperexcitability and dysfunction, which may ultimately result in a chronic pain syndrome. CLINICAL FEATURES The nonneuropathic syndromes share certain characteristics, with the most common feature being muscle-related pain (Table 38-1). A feature common to most neuropathic syndromes is allodynia (Table 38-2). Clinical assessment should be appropriate to the circumstances and either be comprehensive for the unidentified patient or focused for the patient presenting with a typical exacerbation of well-established chronic pain.

related pain (Table 38-1). A feature common to most neuropathic syndromes is allodynia (Table 38-2). Clinical assessment should be appropriate to the circumstances and either be comprehensive for the unidentified patient or focused for the patient presenting with a typical exacerbation of well-established chronic pain. A comprehensive evaluation starts with assessing the quality and character of the patient’s current pain, including initiating, exacerbating, and relieving factors. Compare and quantify prior episodes as they relate to the current episode. Determine sources, modes, and success or failure of prior treatment, including medications and dosages for physician-prescribed, over-the-counter, and alternative medications. Determine the patient’s functionality across the course of the illness and treatment. Treatments that have provided pain relief yet have led to disability cannot be considered a success. Assess any history of alcohol or drug addiction, need for prior detoxification, or psychiatric illness that may impact decisions about choice of medication. A review of systems should assess for potential life- or limb-threatening conditions. Look for findings of acute pain, such as tachypnea, tachycardia, hypertension, and less commonly, diaphoresis or muscle spasms on stimulation, although, for ED patients, there is no correlation between patientreported pain severity and vital signs. 12 Evaluate for muscle atrophy in the distribution of pain due to disuse and skin temperature changes due to the effects of the sympathetic nervous system after disuse or secondary to nerve injury. Trigger points, another objective sign, are focal points of muscle tenderness and tension that, when stimulated with pressure, provoke referred pain, typically in the distribution of the involved muscle. Trigger points are differentiated from simple focal tender portions of the muscle, as trigger points provoke referred pain throughout the affected muscle. Trigger points lack a biologic basis and interexaminer agreement, yet they remain an essential feature of the diagnosis of myofascial pain syndromes. 13 Lack of objective evidence of pain does not rule out the presence of pain.  CLINICAL FEATURES OF SELECTED CHRONIC PAIN SYNDROMES Further discussion of chronic pain, including treatment of chronic back pain, neck pain, and sciatica, is found in Chapter 279, “Neck and Back Pain. ” Migraine headaches and tension headaches are discussed in Chapter 165, “Headache.

t rule out the presence of pain.  CLINICAL FEATURES OF SELECTED CHRONIC PAIN SYNDROMES Further discussion of chronic pain, including treatment of chronic back pain, neck pain, and sciatica, is found in Chapter 279, “Neck and Back Pain. ” Migraine headaches and tension headaches are discussed in Chapter 165, “Headache. ” Medication Overuse Headache History of migraine, depression, using combination analgesics, headache disability, and fear of pain are CHAPTER TABLE 38-1 Symptoms and Signs of Nonneuropathic Pain Syndromes Disorder Pain Symptoms Signs Myofascial headache Constant dull pain, occasionally shooting pain Trigger points on scalp, muscle tenderness and tension Chronic tension headache Constant dull pain Diffuse tenderness of the scalp and associated tension Medication overuse headache May be migraine like, becomes constant, dull; nausea, vomiting Muscle tenderness and tension, normal neurologic exam Myofascial neck pain Constant dull pain, occasionally shooting pain, pain does not typically follow nerve distribution Trigger points in area of pain, usually no muscle atrophy, poor ROM in involved muscle Chronic neck pain Constant dull pain, occasionally shooting pain, pain does not follow nerve distribution No trigger points, poor ROM in involved muscle due to pain Chronic back pain Constant dull pain, occasionally shooting pain, pain does not follow nerve distribution No trigger points, poor ROM in involved muscle due to pain Myofascial back pain syndrome Constant dull pain, occasionally shooting pain, pain does not typically follow nerve distribution Trigger points in area of pain, usually no muscle atrophy, poor ROM in involved muscle Abbreviation: ROM = range of motion. Tintinalli_Sec05_p0229-0266.indd 259 8/2/19 6:35 PM

scle due to pain Myofascial back pain syndrome Constant dull pain, occasionally shooting pain, pain does not typically follow nerve distribution Trigger points in area of pain, usually no muscle atrophy, poor ROM in involved muscle Abbreviation: ROM = range of motion. Tintinalli_Sec05_p0229-0266.indd 259 8/2/19 6:35 PM 260 SECTION 5: Analgesia, Anesthesia, and Procedural Sedation TABLE 38-2 Symptoms and Signs of Neuropathic Pain Syndromes Disorder Pain Symptoms Signs Painful diabetic neuropathy Symmetric numbness and burning or stabbing pain in lower extremities; allodynia may occur Sensory loss in lower extremities Phantom limb pain Variable: aching, cramping, burning, squeezing, or tearing sensation May have peri-incisional sensory loss Trigeminal neuralgia Paroxysmal, short bursts of sharp, electric-like pain in nerve distribution Tearing or red eye may be present HIV-related neuropathy Symmetric pain and paresthesias, most prominent in toes and feet Sensory loss in areas of greatest pain symptoms Postherpetic neuralgia Allodynia; shooting, lancinating pain Sensory changes in the involved dermatome Fibromyalgia and chronic widespread pain Widespread muscular pain in 4 of 5 regions (right upper body, left upper body, torso, right leg, or left leg) for >3 mo, with stiffness, fatigue, sleep disturbance, and cognitive dysfunction (forgetfulness, inability to concentrate or recall simple words or numbers) Widespread point tenderness common, but not required for diagnosis, isolated fibromyalgia does not produce joint inflammation, muscle atrophy, or sensory changes Poststroke pain Same side as weakness; throbbing, shooting pain; allodynia Loss of hot and cold differentiation Sciatica (neurogenic back pain) Constant or intermittent, burning or aching, shooting or electric shock–like pain; may follow dermatome; leg pain > back pain Possible muscle atrophy in area of pain, possible diminished tendon reflexes Complex regional pain syndrome type I Burning persistent pain, allodynia, associated with immobilization or disuse Early: edema, warmth, local sweating Late: above alternates with cold, pale, cyanotic skin; eventually atrophic changes Complex regional pain syndrome type II Burning persistent pain, allodynia, associated with peripheral nerve injury Early: edema, warmth, local sweating Late: above alternates with cold, pale, cyanotic skin; eventually atrophic changes Abbreviation: HIV = human immunodeficiency virus. risk factors for medication overuse headache. 14 The patient may carry the diagnosis of classic or common migraine headaches that change over time and develop into a chronic pain syndrome due to medication overuse.14 Medications implicated in this transition are barbiturates, opioids, triptans, or less commonly, NSAIDs.15 Patients with medication overuse headache may have more symptoms similar to tension headache with tenderness and tension of scalp musculature. Nausea and vomiting or failure of an oral antimigraine medication often prompts an ED visit. In addition to increased headache frequency, headache duration is longer in patients with medication overuse headaches. Fibromyalgia Fibromyalgia is a clinical syndrome of widespread chronic pain associated with fatigue, unrefreshing rest, and/or cogni tive symptoms. Prevalence is thought to be 5.4% of the population. 16 Diagnostic criteria for fibromyalgia were initially proposed in 1977 and most recently updated in 2016. 17 Widespread chronic pain is defined as affecting at least four of five body regions (right upper body including jaw, left upper body including jaw, torso including neck, right leg, and left leg) for more than 3 months.

nostic criteria for fibromyalgia were initially proposed in 1977 and most recently updated in 2016. 17 Widespread chronic pain is defined as affecting at least four of five body regions (right upper body including jaw, left upper body including jaw, torso including neck, right leg, and left leg) for more than 3 months. The nonpain component of fibromyalgia for diagnosis requires a symptom severity score ≥5, calculated from the severity of fatigue (0 to 3 scale), unrefreshed waking (0 to 3 scale), and cognitive symptoms (0 to 3 scale), plus presence of headache, abdominal pain, and depression (1 point each, if present). 17 Patients without fatigue or cognitive symptoms may carry a diagnosis of chronic widespread pain. Painful Diabetic Neuropathy The symptoms of painful diabetic neuropathy are symmetric numbness associated with burning, electrical, or stabbing pain in lower extremities. Patients may have hyperesthesia, dysesthesias, and/or deep aching pain. Pain may be provoked with a gentle touch to the skin in the areas of abnormal sensation. Postherpetic Neuralgia Postherpetic neuralgia may follow the course of an acute episode of herpes zoster in 5% to 30% of cases; pain lasts more than 1 year for 30% of patients. 18 Pain is characterized by allodynia and a shooting, lancinating (tearing or sharply cutting) sensation. Often, patients have hyperesthesia in the involved dermatome. Occasionally there are pigmentation changes in the distribution of the involved der matome, but this is not unique to postherpetic neuralgia. Trigeminal Neuralgia Typical symptoms of trigeminal neuralgia include short, paroxysmal bursts of sharp, electric shock–like pain in the nerve distribution of the trigeminal nerve. Pain is often triggered by chewing, speaking, washing, brushing teeth, or something touching the face. Tearing of the eyes or red eye may be present. Phantom Limb Pain Phantom limb pain is quite variable in pre sentation but occurs more frequently in patients who had pain in the extremity before amputation. Pain may be described as aching, cramp ing, burning, tearing, or squeezing. Phantom limb pain occurs in 30% to 81% of amputations and changes over years, typically becoming less knife-like and more burning in character. Complex Regional Pain Syndrome There are two types of complex regional pain syndrome: type I, from prolonged immobilization or disuse, as after stroke; and type II, from a peripheral nerve injury (e.g., due to fracture or gunshot). Symptoms include allodynia and a persistent burning or shooting pain on the affected side or limb. Associated signs early in the course of the disease include edema, warmth, and localized abnormal sweating. It may be difficult to distinguish this stage from an underlying wound infection or osteomyelitis. Later signs include periods of edema and warmth that alternate with cold, pale, cyanotic skin and, eventually, atrophic changes. Human Immunodeficiency Virus–Related Pain Patients with acquired immunodeficiency syndrome can develop distal sensory poly neuropathy characterized by shooting pain, numbness, and burning sensations, primarily on the soles, dorsum of the feet, and toes. This human immunodeficiency virus–related sensory neuropathy is associated with antiretroviral therapy but not with low CD4 counts. 20 Sensory loss is common in the areas of greatest pain symptoms. As the neuropathy progresses, walking becomes difficult, and quality of life is diminished.  CHRONIC ABDOMINAL AND PELVIC PAIN SYNDROMES By definition, these disorders lack features to suggest impending lifethreatening complications or a need for surgical intervention. However, these syndromes may present with transient tachycardia or tachypnea in response to the patient’s pain experience.

ife is diminished.  CHRONIC ABDOMINAL AND PELVIC PAIN SYNDROMES By definition, these disorders lack features to suggest impending lifethreatening complications or a need for surgical intervention. However, these syndromes may present with transient tachycardia or tachypnea in response to the patient’s pain experience. Furthermore, patients experiencing significant vomiting (or less commonly diarrhea) may be dehydrated on initial presentation and therefore may have hypotension due to hypovolemia. Patients with isolated exacerbations in pain will lack alarm signs, such as unintentional weight loss, palpable abdominal mass, significant fever, or positive fecal blood (see later “Diagnosis” section for discussion of laboratory testing). The patient should be asked Tintinalli_Sec05_p0229-0266.indd 260 8/2/19 6:35 PM

Patients with isolated exacerbations in pain will lack alarm signs, such as unintentional weight loss, palpable abdominal mass, significant fever, or positive fecal blood (see later “Diagnosis” section for discussion of laboratory testing). The patient should be asked Tintinalli_Sec05_p0229-0266.indd 260 8/2/19 6:35 PM CHAPTER 38: Chronic Pain 261 about prior episodes, and to describe any unique aspects to the current presentation. An atypical presentation suggests the need to broaden the differential diagnosis to include acute disorders. Chronic Pain Syndromes of the Esophagus and Stomach Esophageal and gastric pain syndromes typically present with epigastric and/or chest pain, with or without vomiting (Table 38-3). 21-23 Upper endoscopy is TABLE 38-3 Signs and Symptoms of Chronic Pain Syndromes of the Esophagus and Stomach Disorder Pain Symptoms Signs Functional heartburn Retrosternal burning discomfort or pain present longer than 6 months that is refractory to optimal antisecretory therapy (H 2 blockers and proton pump inhibitors) in patients without endoscopic evidence of GERD, histopathologic mucosal abnormalities, GI motor disorders, or structural explanations. Normal upper endoscopy, no correlation between symptoms and endoscopic evidence of physiologic reflux. Absence of alarm signs. * Reflux hypersensitivity Retrosternal heartburn or chest pain present longer than 6 months in patients who lack evidence of reflux on endoscopy or abnormal acid burden on reflux monitoring, but show triggering of symptoms by physiologic reflux (some degree of reflux is considered normal, such as postprandial reflux). Normal upper endoscopy, positive correlation between symptoms and endoscopic evidence of physiologic reflux. Absence of alarm signs. * Functional dyspepsia with epigastric pain syndrome Bothersome epigastric pain or epigastric burning for ≥6 months. Symptoms severe enough to significantly limit meals or limit daily activities at least 1 day per week. Significant vomiting suggests another disorder. No evidence of structural disease on endoscopy. Pain may be induced or relieved by a meal. Absence of alarm signs. * Cyclic vomiting syndrome (with pain) Stereotypical episodes of vomiting with acute onset and duration lasting a week or less; ≥3 discrete episodes in the previous year; absence of nausea and vomiting characterize symptom-free periods lasting weeks to months. Personal or family history of migraine headache supports the diagnosis. Upper endoscopy is normal or does not reveal cause of repeated vomiting. Absence of alarm signs. * Gastroparesis with pain Patients with gastroparesis may have frequent visits to the ED with vomiting and abdominal pain and distention. Pain may be a primary complaint, especially for patients with recurrent symptoms. Absence of alarm signs. * Distention may occur in the absence of small bowel obstruction. Assess for dehydration. Cannabinoid hyperemesis syndrome Stereotypical episodic abdominal pain and vomiting after prolonged excessive cannabis use with 3 or more episodes in the past year. Relief of vomiting episodes by hot showers, often for hours at a time. Urine drug screen positive for cannabinoids. If performed, upper endoscopy is normal. Absence of alarm signs. * *Alarm signs: unintentional weight loss, abdominal mass, positive fecal blood, anemia, hypoalbuminemia, abnormal liver function tests, elevated erythrocyte sedimentation rate, and elevated C-reactive protein. Abbreviation: GERD = gastroesophageal reflux disease. necessary to differentiate these disorders from acute disorders, and therefore, a clinical diagnosis is only preliminary. Eliciting a history of cannabis use is essential in identifying cannabinoid hyperemesis syndrome (Table 38-3).

and elevated C-reactive protein. Abbreviation: GERD = gastroesophageal reflux disease. necessary to differentiate these disorders from acute disorders, and therefore, a clinical diagnosis is only preliminary. Eliciting a history of cannabis use is essential in identifying cannabinoid hyperemesis syndrome (Table 38-3). Chronic Pain Syndromes of the Bowel Centrally mediated abdominal pain syndrome (formerly, functional abdominal pain syndrome) requires repeated episodes to meet criteria for diagnosis ( Table 38-4). 23-27 By the TABLE 38-4 Signs and Symptoms of Chronic Pain Syndromes of the Bowels Disorder Pain Symptoms Signs Centrally mediated abdominal pain syndrome (formerly, functional abdominal pain syndrome) Near-continuous abdominal pain (6 months or longer); no or only occasional relationship of pain to physiologic events (e.g., eating, defecation, or menses); pain limits daily functioning; pain is not explained by another structural or functional disorder. Patients may previously have had a disorder causing abdominal pain with a clear anatomic basis or that required prior surgery. Absence of alarm signs *; may have voluntary guarding, frequently has had prior surgery, may have had surgery for lysis of adhesions. Narcotic bowel syndrome Must include all 3 of the following criteria: 1. Chronic or recurrent abdominal pain that is treated with acute high-dose or chronic narcotics. 2. The nature and intensity of the pain is not explained by a current or previous GI diagnosis. 3. Two or more of the following: a. The pain worsens or incompletely resolves with continued or escalating dosages of narcotics. b. There is marked worsening of pain when the narcotic dose wanes and improveme nt when narcotics are reinstituted (soar and crash). c. There is a progression of the frequency, duration, and intensity of pain episodes. Absence of alarm signs*; may have voluntary guarding. Would be expected to test positive for opioids, unless test is not specific to the opioids taken chronically. Irritable bowel syndrome (IBS) with pain (2 types: IBS–diarrhea predominant and IBS–constipation predominant) Recurrent abdominal pain, on average, at least 1 day per week in the past 3 months, associated with 2 or more of the following criteria: (1) related to defecation, (2) associated with a change in frequency of stool (diarrhea or constipation), or (3) associated with a change in form (appearance) of stool. May have bloating or distention. May have had multiple imaging studies. Patients with depression and anxiety seek care for abdominal pain more frequently. Inflammatory bowel disease, Crohn’s disease, and ulcerative colitis Recurring episodes of crampy abdominal pain, fatigue, and diarrhea, with or without fever and blood per rectum, are typical symptoms of Crohn’s disease and ulcerative colitis. Twenty percent of patients with inflammatory bowel disease have chronic abdominal pain despite resolving inflammation and clinical remission; chronic opioid use is associated with exacerbations of pain in the absence of active bowel wall inflammation. Coexisting diagnosis of irritable bowel syndrome associated with chronic opioid use. Exacerbations of chronic pain should be distinguished from exacerbations in bowel wall inflammation using both clinical and objective factors; smoking, prior outpatient opioid use, and psychiatric diagnoses are associated with exacerbations of chronic pain. *Alarm signs: unintentional weight loss, abdominal mass, positive fecal blood, anemia, hypoalbuminemia, abnormal liver function tests, elevated erythrocyte sedimentation rate, and elevated C-reactive protein. Tintinalli_Sec05_p0229-0266.indd 261 8/2/19 6:35 PM

iagnoses are associated with exacerbations of chronic pain. *Alarm signs: unintentional weight loss, abdominal mass, positive fecal blood, anemia, hypoalbuminemia, abnormal liver function tests, elevated erythrocyte sedimentation rate, and elevated C-reactive protein. Tintinalli_Sec05_p0229-0266.indd 261 8/2/19 6:35 PM 262 SECTION 5: Analgesia, Anesthesia, and Procedural Sedation TABLE 38-5 Signs and Symptoms of Chronic Pelvic Pain Disorders Disorder Pain Symptoms Signs Endometriosis Defined as the presence of endometrial glands and stroma outside of the normal location, typically over pelvic peritoneum or ovaries. Pain is constant (noncyclic) in middle to lower pelvis, but may slowly intensify. Dysmenorrhea or dyspareunia may herald worsening of pain or be the presenting complaint. Uncommonly, there is dysuria (bladder involvement) or pain with defecation (rectosigmoid involvement). Diagnosis is usually made with laparoscopy or MRI. Patients with postcoital bleeding, postmenopausal bleeding, weight loss, pelvic mass, or hematuria should have further testing or referral. Post–pelvic inflammatory disease (PID) chronic pelvic pain 30%–36% of patients treated for PID develop chronic pain. An exacerbation of chronic pelvic pain in a patient with prior PID is unlikely to be associated with fever, mucopurulent discharge, cervical friability, elevated C-reactive protein, or erythrocyte sedimentation rate. Patients with postcoital bleeding, postmenopausal bleeding, or weight loss should have further testing or referral. Patients often have cervical motion tenderness, possibly with uterine and adnexal tenderness. Patients with pelvic mass or hematuria should have further testing or referral. Interstitial cystitis/bladder pain syndrome Suprapubic pain, occasionally radiating to groin, vagina, rectum, or sacrum, exacerbated by bladder fullness and relieved partially by voiding. Symptoms are worsened by fluid intake. Suprapubic tenderness, negative urinalysis; cystoscopy commonly performed but controversial. time of diagnosis, narcotic bowel syndrome may coexist or dominate the clinical picture. 24 It is important to differentiate these chronic syn dromes from acute disorders, but this task may be difficult for both the patient and the physician. Prior records are helpful to identify the patient’s typical presentation. Patient with inflammatory bowel disease my present with exacerbations of the underlying disease, chronic non inflammatory pain, or coexistent irritable bowel syndrome . 26,27 Differentiation of these disorders may require more than history and physical examination. Chronic Pelvic Pain Syndromes Chronic pelvic pain be due to more than one etiology (Table 38-5), and consideration should be given to coexistent syndromes, such as irritable bowel syndrome, or other chronic abdominal pain syndromes (Table 38-3). 28-31 If the history suggests an atypical presentation of pain or related symptoms, a pelvic exam should be done to rule out new palpable pathology. The most common diagnosis at the time of laparoscopy for the evaluation of chronic pelvic pain in woman is endometriosis; however, endometriosis may exist without pain. 28 Post–pelvic inflammatory disease pain and intersti tial cystitis (bladder pain syndrome) are common causes of chronic abdominal pain.29,30 DIAGNOSIS The most important task is to distinguish an exacerbation of chronic pain from a life- or limb-threatening condition. The history and physi cal examination should either confirm the chronic condition or point to the need for further evaluation when unexpected signs or symptoms are elicited. Because patients with chronic pain may be frequent visitors to the ED, the entire staff may prejudge complaints as simply chronic or even factitious.

history and physi cal examination should either confirm the chronic condition or point to the need for further evaluation when unexpected signs or symptoms are elicited. Because patients with chronic pain may be frequent visitors to the ED, the entire staff may prejudge complaints as simply chronic or even factitious. Follow routine procedures, including a standard triage assessment and a complete set of vital signs. After eliminating potential conditions that require emergent treat ment, clinical judgment determines if focused management of pain is an appropriate course of action in the ED. The principles of focused management are to identify that symptoms are an exacerbation or con tinuation of a chronic pain pattern, provide appropriate rescue therapy for pain relief, and reinforce the need for a single provider (physician or clinic) for ongoing pain management. Rarely is a provisional diagnosis of a chronic pain condition made for the first time in the ED. Definitive assessment for chronic pain conditions is difficult and requires expert opinion and often advanced procedures such as MRI, CT, and thermography. Furthermore, abnormal results usually do not confirm with certainty the cause of pain. For example, abnormalities on MRI of the spine and extremities are common in both asymptomatic and symptomatic patients. Therefore, referral back to the primary source of care is warranted to confirm the diagnosis. The diagnosis of a chronic abdominal or pelvic pain syndrome is clinically based (Tables 38-3 to 38-5) but frequently requires testing to exclude other disorders. A specialist is best suited to make the diagnosis of these syndromes (specialist type will depend on the syndrome). However, emergency physicians who suspect a diagnosis should refer the patient for confirmation. When laboratory investigation is warranted by an atypical presentation or physician suspicion of an acute disorder, the presence of a new anemia, elevated white blood cell count, elevated creatinine, hypoalbuminemia, abnormal liver function tests, elevated erythrocyte sedimentation rate, or elevated C-reactive protein may warrant imaging or other additional testing. Stable patients can be discharged to follow-up for further testing. When the diagnosis cannot be determined during the ED visit, patient acuity should determine the need for admission. TREATMENT  OPIOIDS FOR CHRONIC PAIN Opioids are not recommended for the ED treatment of chronic pain. The use of opioids to treat chronic, noncancer pain in the United States increased rapidly from 1986 to 2010. 32,33 A similar increase in opioid prescribing was seen upon ED discharge, from 20.8% to 31.0% between 2001 and 2010. 34,35 With the growth in opioid prescribing, the ageadjusted rate for opioid-analgesic poisoning deaths nearly quadrupled from 1.4 per 100,000 in 1999 to 5.4 per 100,000 in 2011. 36 Poisoning is now the most common cause of injury-related death in the United States, surpassing motor vehicle–related death. In response to the dramatic increase in opioid-analgesic poisoning, state agencies created statewide prescription drug monitoring programs accessible by the Internet for registered medical providers to view controlled substance prescriptions that a patient has received. 37-39 Although helpful, drug monitoring programs have not been shown to reduce opioid prescribing. 40 In contrast, individual hospital opioid-prescribing policies reduce opioid prescribing. 41 The American College of Emer gency Physicians, individual states, and the Centers for Disease Control and Prevention have issued guidelines on the prescription of opioids for patients discharged from the ED (Table 38-6). 42-45  CANNABIS FOR CHRONIC PAIN Many patients with chronic pain self-medicate with cannabis.

. 41 The American College of Emer gency Physicians, individual states, and the Centers for Disease Control and Prevention have issued guidelines on the prescription of opioids for patients discharged from the ED (Table 38-6). 42-45  CANNABIS FOR CHRONIC PAIN Many patients with chronic pain self-medicate with cannabis. 46 Medical use of cannabis has significant health risks but may offer benefits in some patients. 47,48  TREATMENT OF CHRONIC NONNEUROPATHIC PAIN SYNDROMES Evidence-based treatment for chronic nonneuropathic pain syn dromes is divided into primary and secondary treatment modalities (Table 38-7). 49-55 For management in the ED, an acute exacerbation of a chronic migraine can be treated like an exacerbation of episodic migraine (see Chapter 165, “Headache”). Treatment in the ED should never be regarded as definitive, and follow-up care is essential. Many emergency providers will elect to Tintinalli_Sec05_p0229-0266.indd 262 8/2/19 6:35 PM

ED, an acute exacerbation of a chronic migraine can be treated like an exacerbation of episodic migraine (see Chapter 165, “Headache”). Treatment in the ED should never be regarded as definitive, and follow-up care is essential. Many emergency providers will elect to Tintinalli_Sec05_p0229-0266.indd 262 8/2/19 6:35 PM CHAPTER 38: Chronic Pain 263 TABLE 38-6 Summary of Key Guideline Recommendations for Prescribing Opioids to Adult Patients in the ED 42-45 *For the treatment of back pain, given a lack of demonstrated evidence of superior efficacy of either opioid or nonopioid analgesics, and the individual and community risks associated with opioid use, misuse, and abuse, opioids should be reserved for more severe pain or pain refractory to other analgesics rather than routinely prescribed. †If opioids are indicated, the prescription should be for the lowest practical dose for a limited duration (e.g., 3 days), and the prescriber should consider the patient’s risk for opioid misuse, abuse, or diversion. *Emergency providers should avoid the routine prescribing of outpatient opioids for a patient with an acute exacerbation of chronic noncancer pain seen in the ED. *The clinician should, if practicable, honor existing patient–physician pain contracts/ treatment agreements. *The clinician should, if practicable, consider past prescription patterns from information sources such as prescription drug monitoring programs. ‡The administration of IV and IM opioids in the ED for the relief of acute exacerbations of chronic pain is discouraged. ‡Emergency medical providers should not provide replacement prescriptions for con trolled substances that were lost, destroyed, or stolen. ‡Long-acting or controlled-release opioids (such as OxyContin ® , fentanyl patches, and methadone) should not be prescribed from the ED. ‡Prescriptions for controlled substances from the ED should state that the patient is required to provide a government-issued picture identification (ID) to the pharmacy filling the prescription. ‡Emergency medical providers should not provide replacement doses of methadone for patients in a methadone treatment program. ‡If the emergency medical provider decides to prescribe opioids to a patient with chronic pain, the provider should only prescribe enough pills to last until the office of the patient’s primary opioid prescriber opens. *2012 American College of Emergency Physicians policy. †Centers for Disease Control and Prevention guidelines. ‡Washington State Opioid Prescribing guidelines.

ioids to a patient with chronic pain, the provider should only prescribe enough pills to last until the office of the patient’s primary opioid prescriber opens. *2012 American College of Emergency Physicians policy. †Centers for Disease Control and Prevention guidelines. ‡Washington State Opioid Prescribing guidelines. TABLE 38-7 Management of Nonneuropathic Chronic Pain Syndromes Disorder Primary Treatment Secondary Treatment Possible Referral Outcome Myofascial pain syndromes NSAIDs orally, topical diclofenac patch for single site of pain Amitriptyline Trigger point injections or dry needling, US treatments, optimization of medical therapy, recommendations for exercise Chronic migraine headache See Chapter 165, “Headache,” for treatment of acute exacerbations Prophylaxis with sodium valproate or topiramate Optimization of medical therapy, evaluation for use of prophylactic onabotulinumtoxinA Medication overuse headache Stop prior medications Celecoxib or prednisone taper during withdrawal period Optimization of medical therapy, withdrawal of prior medications, evaluation for use of prophylactic onabotulinumtoxinA Medication dosing for above indications: amitriptyline 25 milligrams PO at bedtime; celecoxib 400 milligrams PO per day for the first 5 days, then decreased at a rate of 100 milligrams every 5 days; diclofenac 1.3% patch every 12 hours over single site of focal pain; prednisone 60 milligrams PO per day for the first 5 days then tapered down to a dose of 20 milligrams every 5 days; sodium valproate 250 milligrams PO two times daily; topiramate 25 milligrams PO at bedtime during first week, then 25 milligrams two times daily during second week, with further dose adjustments at follow-up. prescribe short-acting nonspecific pain medications (Table 38-7) for patients with chronic pain, deferring initiating of more specific therapy for the primary care physician or pain specialist. Specialty referral may provide optimization of therapy, trigger point injections, and novel treatments, such as onabotulinumtoxinA injections.  TREATMENT OF CHRONIC NEUROPATHIC PAIN SYNDROMES Evidence-based treatment for chronic neuropathic pain syndromes is divided into primary and secondary treatment modalities (Table 38-8). 56-69 There is no convincing unbiased evidence to support the use of opioids (specifically oxycodone) in the treatment of neuropathic pain, including fibromyalgia. 70 Duloxetine is favored over pregabalin and gabapentin in the treatment of painful diabetic neuropathy. 65 Human immunodeficiency syndrome–related neuropathy is resistant to many therapies commonly used for neuropathic pain; gabapentin is recommended. Topical capsaicin is effective for chronic neuropathic pain, 60 but is best directed by a specialist because pain increases at first application and pretreatment with topical lidocaine may be required. Phantom limb pain responds poorly to medication 62; mirror therapy provides some benefit.63 Poststroke pain responds poorly to most therapies.64 Tramadol reduces pain in most neuropathic pain syndromes, but is considered secondary treatment because it is less effective than the primary treatments (Table 38-8). 60,71 Complex regional pain syndrome is resistant to most therapies.69 An IV infusion of ketamine may reduce pain for up to 12 weeks69 but does not improve function. Corticosteroids (prednisone, 60 milligrams PO once a day) have been recommended at the time of first diagnosis when signs of inflammation are present, but steroids do not affect the course of illness. Although considered second line, cyclic antidepressants are effective therapy for most patients with neuropathic pain, except spinal cord injury pain, phantom limb pain, human immunodeficiency virus–related neuropathy, and chronic regional pain syndrome.

on are present, but steroids do not affect the course of illness. Although considered second line, cyclic antidepressants are effective therapy for most patients with neuropathic pain, except spinal cord injury pain, phantom limb pain, human immunodeficiency virus–related neuropathy, and chronic regional pain syndrome. Amitriptyline can be started at 25 milligrams PO nightly and escalated by the follow-up clinician. Complete relief of pain is an unrealistic goal for patients with chronic pain, both for the ED visit and for follow-up care; patients should be informed of this limita tion early in their ED course.  TREATMENT OF CHRONIC ABDOMINAL AND PELVIC PAIN SYNDROMES Patients with chronic abdominal and pelvic pain syndromes may require acute treatment (Table 38-9). 21,22,28,72-87 Potent opioid analgesics are associated with narcotic bowel syndrome81 and should be avoided, unless a single dose is required to obtain an abdominal examination to minimize voluntary guarding. 88 Antinausea medication and IV fluids may be required. Nonopioid analgesics should be provided as the individual case requires, provided that the known side effect profile of the drug would not worsen the patient’s condition (e.g., NSAIDs exacerbating gastritis).  TREATMENT OF CHRONIC PAIN IN THE ELDERLY AND MENTALLY IMPAIRED The prevalence of chronic pain increases with age. 1 Opioid analgesic alternatives, such as NSAIDs, have side effects that may limit their use in the elderly who are prone to GI and renal complications; however, when compared to opioids, NSAIDs have fewer side effects overall and are less likely to lead to premature death in the elderly. 89 GI bleeding rates are similar for patients treated with opiates or nonselective NSAIDs and lower for those treated with cyclooxygenase-2 inhibitors. 89 NSAIDs should not be given to patients with renal dysfunction. Topical anal gesics (lidocaine 5% or capsaicin 8%) are effective 90 and can be given alone or as adjuncts. Topical NSAIDs provide excellent joint and tissue levels with low plasma levels and are available as diclofenac gel, patch, or topical solution. Cognitively and mentally impaired adults with chronic pain are at risk for inadequate pain control due to barriers in communicating the nature and intensity of their pain. Be alert to these potential barriers and look for nonverbal signs of pain: agitation, irregular breathing, facial expressions Tintinalli_Sec05_p0229-0266.indd 263 8/2/19 6:35 PM

ired adults with chronic pain are at risk for inadequate pain control due to barriers in communicating the nature and intensity of their pain. Be alert to these potential barriers and look for nonverbal signs of pain: agitation, irregular breathing, facial expressions Tintinalli_Sec05_p0229-0266.indd 263 8/2/19 6:35 PM 264 SECTION 5: Analgesia, Anesthesia, and Procedural Sedation TABLE 38-8 Management of Neuropathic Chronic Pain Disorder Primary Treatment Secondary Treatment Possible Referral Outcome Fibromyalgia Pregabalin Duloxetine Exercise program; optimization of medical therapy Trigeminal neuralgia Carbamazepine Oxcarbazepine Optimization of medical therapy; consideration for surgery or radiation HIV-related neuropathy pain Gabapentin Topical capsaicin Optimization of medical therapy including antiretroviral medications Spinal cord pain Pregabalin Tramadol Optimization of medical therapy Painful diabetic neuropathy Duloxetine Gabapentin or pregabalin Optimization of medical therapy Postherpetic neuralgia Pregabalin or gabapentin Lidocaine patch Optimization of medical therapy; regional nerve blockade Phantom limb pain Gabapentin Referral for mirror therapy Optimization of medical therapy; ketamine infusion Poststroke pain Pregabalin Gabapentin Optimization of medical therapy Complex regional pain syndrome types I and II (reflex sympathetic dystrophy and causalgia) Acute phase: prednisone Chronic: intermittent ketamine, bisphosphonates, by specialist Physical therapy, individualized therapy based on neuro logic testing Dosing for above indications can be started as follows: capsaicin is best started at follow-up as pain increases before it decreases; carbamazepine 100 milligrams PO two times daily; duloxetine 30 to 60 milligrams PO daily; gabapentin 300 milligrams PO, once on day 1, two times day 2, then three times daily, eventually increasing to 1200 milligrams per day guided by follow-up clinician; lidocaine patch 5%, up to three patches at a time, apply for up to 12 hours per day; oxcarbazepine 300 milligrams PO two times daily for 3 days, 300 milligrams at morning and 600 milligrams at evening for 3 days, then 600 milligrams two times daily; prednisone 60 milligrams PO daily for 7 days to be adjusted by follow-up physician; pregabalin 50 milligrams PO three times per day; tramadol 50 milligrams PO every 6 hours as needed. Abbreviation: HIV = human immunodeficiency virus. TABLE 38-9 Treatment of Selected Chronic Abdominal and Pelvic Pain Syndromes Disorder Primary Management Secondary Management Functional heartburn* Citalopram, other agents. Behavioral modification. Reflux hypersensitivity* Standard-dose or double-dose proton pump inhibitor. Citalopram, other agents. Functional dyspepsia with epigastric pain syndrome * Amitriptyline; frequent, small, low-fat meals; avoid NSAIDs. Proton pump inhibitors, H2 blockers, Helicobacter pylori eradication. Cyclic vomiting syndrome (with pain) Rehydration with 0.9% normal saline including dextrose; give ondansetron, ketorolac but opioids or lorazepam may be required for acute vomiting. Avoidance of triggers (stress, poor sleep, infections), management of common coexisting disorders (irritable bowel syndrome, migraine headaches, gastroparesis, and anxiety). Cannabinoid hyperemesis syndrome Stop cannabinoids; treat with antiemetics and hydration as for cyclic vomiting; avoid opioids. Substance abuse treatment as necessary, amitriptyline for recurrent cases. Centrally mediated abdominal pain syndrome (formerly, functional abdominal pain syndrome) Specialty care for chronic abdominal pain; avoid opioids; amitriptyline first line for chronic management. Consider substituting duloxetine, add quetiapine.

ubstance abuse treatment as necessary, amitriptyline for recurrent cases. Centrally mediated abdominal pain syndrome (formerly, functional abdominal pain syndrome) Specialty care for chronic abdominal pain; avoid opioids; amitriptyline first line for chronic management. Consider substituting duloxetine, add quetiapine. Gastroparesis-related pain and vomiting * Haloperidol reduces pain and need for hospital admission when compared to other antiemetics. Standard antiemetics and IV fluids. Narcotic bowel syndrome May require admission with 15%–30% reduction in daily narcotic dose per day; give antiemetics for vomiting and benzodiazepines for anxiety as needed. Augment first day with amitriptyline and continue at discharge. For outpatient management, consider 4- to 6-week withdrawal duration. Maintenance of antidepressant therapy and ongoing outpatient care for prevention of repeat ED visits. Irritable bowel syndrome (IBS) with pain (2 types: IBS–diarrhea predominant and IBS–constipation predominant) For constipation: psyllium, polyethylene glycol. For pain: dicyclomine and/or amitriptyline. Change in diet (per specialist, after testing); for resistant symptoms, lubiprostone, linaclotide, and other medications. Inflammatory bowel disease, Crohn’s disease, and ulcerative colitis Acute medical management discussed in Chapter 73, “Disorders Presenting Primarily With Diarrhea.” Parenteral opioids are given in 70% of hospitalizations; outpatient opioids should be limited and/or replaced with dicyclomine and amitriptyline. Endometriosis Progesterone orally (or long-acting injection at follow-up). NSAIDs. Levonorgestrel-releasing intrauterine system or goserelin at follow-up. Post–pelvic inflammatory disease chronic pelvic pain NSAIDs are the most common treatment for pain. Empiric treatment for possible reinfection of a sexually transmitted disease should be considered. Amitriptyline, with or without gabapentin. Interstitial cystitis/bladder pain syndrome Amitriptyline. Pentosan polysulfate sodium (coating agent), hydroxyzine, gabapentin. *Referral to specialist in chronic abdominal pain or gastroenterologist that performed the original endoscopy. Note: Dosing for above indications can be started as follows: amitriptyline 10 to 25 milligrams daily at bedtime; citalopram 20 milligrams daily; dicyclomine 10 to 20 milligrams up to four times daily; duloxetine 30 to 60 milligrams daily; gabapentin, 300 milligrams PO, once on day 1, two times on day 2, then three times daily; haloperidol 5 milligrams IV; ketorolac 15 to 30 milligrams IV; linaclotide 290 micrograms daily; lorazepam 1 to 2 milligrams; lubiprostone 8 micrograms twice daily; ondansetron 4 to 8 milligrams acutely; polyethylene glycol 17 to 34 grams daily; progesterone 5 to 10 milligrams daily; psyllium up to 30 grams per day divided two to three times daily; quetiapine 25 to 100 milligrams daily; hydroxyzine 25 milligrams every 6 to 8 hours. Tintinalli_Sec05_p0229-0266.indd 264 8/2/19 6:35 PM

dansetron 4 to 8 milligrams acutely; polyethylene glycol 17 to 34 grams daily; progesterone 5 to 10 milligrams daily; psyllium up to 30 grams per day divided two to three times daily; quetiapine 25 to 100 milligrams daily; hydroxyzine 25 milligrams every 6 to 8 hours. Tintinalli_Sec05_p0229-0266.indd 264 8/2/19 6:35 PM CHAPTER 38: Chronic Pain 265 of pain, stiffened body positioning, and reports of irregular sleep patterns. Undesired side effects, such as sedation, may limit the use of cer tain pain medications in this population. DISPOSITION AND FOLLOW-UP Referral to an appropriate specialist is one of the most productive means of aiding in the care of chronic pain patients who present to the ED. Chronic pain clinics have been successful in changing the lives of patients by eliminating opioid use, decreasing medication use, reducing pain levels, and increasing work hours. Patients’ compliance with pain clinics may improve if these benefits are explained. Admission to the hospital is rarely indicated. However, occasionally patients may be admitted for pain control, possibly using self-controlled analgesic administration.  ABERRANT DRUG-RELATED BEHAVIOR INTRODUCTION The term drug-seeking behavior is imperfect, and its definition varies among clinicians. A more accurate term is aberrant drug-related behavior, which raises concern for addiction and opioid misuse (Table 38-10). The spectrum of people seeking controlled drugs includes those who have chronic pain and have been prescribed limited opioids, the drug addict who is trying to supplement a habit, and the “hustler” who is obtaining prescription drugs to sell on the street. However, the ability of the physician to correctly identify individuals in any of these three categories is difficult and imperfect. The prevalence of aberrant drug-related behaviors is not known; however, there is considerable indirect evidence of the problem. A sys tematic review of the literature found that the only consistent predictor of aberrant drug-related behaviors in chronic pain patients is a personal history of illicit drug and alcohol abuse. 91 A separate systematic review of chronic nonmalignant pain patients exposed to chronic opioid anal gesic therapy found that 20.4% of patients had negative urine tests for prescribed opioids despite filling regular prescriptions, and 14.5% tested positive for illicit drugs. 92 In 2012, 17% of the teens trying illicit drugs for the first time used prescription opioids, second only to marijuana. 93 Individuals attempting to secure opioids from emergency providers are often successful through persistence. CLINICAL FEATURES The history given may be factual or fraudulent. Patients may be demanding, intimidating, or flattering. The most common complaints of patients who attempt to obtain opioids from the ED are (in decreasing order) back pain, headache, extremity pain, and dental pain. 94 Patients may complain of panic disorder or drug withdrawal symptoms and request benzodiazepines. In some cases, observation of vital signs and physical examination findings will help identify factitious illness, but even experienced clinicians are frequently misled. Patients should be examined for signs of injection drug use, includ ing needle marks, and the heart should be examined for evidence of a regurgitant murmur indicative of valve damage from prior endocardi tis. Look for key characteristics of patients attempting to falsify illness (Table 38-11). Patients most commonly have completely normal physical examination findings. Widespread anecdotal experience of ED personnel has indicated that such patients will relate an allergy to alternative pharmacotherapy and insist that only one or two specific opioids are effective.

attempting to falsify illness (Table 38-11). Patients most commonly have completely normal physical examination findings. Widespread anecdotal experience of ED personnel has indicated that such patients will relate an allergy to alternative pharmacotherapy and insist that only one or two specific opioids are effective. TABLE 38-11 Recommendations to Manage Fraudulent Techniques Used by Patients Attempting to Obtain Opioids for Illicit Use Technique Characteristics Management Lost prescription Calls or returns stating that opioid prescription was lost before being filled. Establish a policy: no lost opioid prescriptions refilled. Notify patients of policy at discharge as they receive prescriptions. “Stolen” prescription or pill bottle Police have not been called. Inform patient this is a police issue and recommend calling police to rectify matter. Establish a policy: no stolen opioid prescriptions refilled. Impending surgery Wants temporizing opioids, doctor “unavailable,” previous surgery, patient from out of town. Use Internet and phone calls to check validity of information. Check medical records. Offer substitute for opioid. Carries own records and radiographs Suspicious or forged records, doctor’s written permission to receive opioids, patient from out of town. Use Internet and phone calls to check validity of information. Check medical records. Offer substitute for opioid. Factitious hematuria with complaint of kidney stones Appears comfortable or overacting, pricked finger dipped in urine, lip/cheek bitten and blood spat into urine. Examine fingers and mouth. Obtain witnessed urinalysis. Offer nonopioid pain medicine. Obtain confirmatory test before giving opioid. Self-mutilation Done with dominant hand, requests opioids for pain. Use bupivacaine for local block. Do not prescribe opioids without indications. Offer substitute for opioids. Dental pain Dental caries only. Perform local nerve block with bupivacaine. Refer to dentist. Factitious injury Old injury, old deformity, self-massaged to produce erythema; patient from out of town. Radiograph before treatment. Check medical records. Check for erythema that dissipates over time. TABLE 38-10 Aberrant Drug-Related Behaviors •  Forges/alters  prescriptions* •  Sells  controlled substances* •  Uses  aliases to receive opioids* •  Current  illicit drug use* •  Factitious  illness, requests opioids •  Conceals  multiple physicians prescribing opioids •  Abusive  when refused •  Conceals  multiple ED visits for opioids *Unlawful behaviors in many states. Tintinalli_Sec05_p0229-0266.indd 265 8/2/19 6:35 PM

s* •  Uses  aliases to receive opioids* •  Current  illicit drug use* •  Factitious  illness, requests opioids •  Conceals  multiple physicians prescribing opioids •  Abusive  when refused •  Conceals  multiple ED visits for opioids *Unlawful behaviors in many states. Tintinalli_Sec05_p0229-0266.indd 265 8/2/19 6:35 PM 266 SECTION 5: Analgesia, Anesthesia, and Procedural Sedation DIAGNOSIS The diagnosis of aberrant drug-related behavior may not be possible in the ED. The medical record can provide a wealth of information about the patient, including documentation proving that the patient is supplying false information. Often the diagnosis is suspected in the ED but cannot be confirmed. In such cases, the clinical impression should be documented in the chart listing the provider’s concerns, but physi cians should be careful when using terms such as drug-seeking behavior; instead, document the concerning facts. Electronic medical records can be programmed to flag charts with alerts for patient safety; accidental overdose is always a concern in such patients. Do not miss a true emergency in patients suspected of aberrant drug-related behaviors because the negotiation over pain medicine can distract the entire team from a subtle yet life-threatening medical or surgical illness. Prescription drug monitoring programs 39 and other computerized tracking systems help identify patients who are abusing or overusing prescription drugs. Practitioners are encouraged to review the prescription drug monitoring program database before prescribing a discharge medication, because that information may change the intended discharge plan. TREATMENT AND DISPOSITION The treatment of definite aberrant drug-related behavior is to refuse the controlled substance, consider the need for alternative medication or treatment, and refer for drug counseling. When confronted, patients hoping to acquire opioids may become verbally abusive, and hospital security may be required to control the situation and, if necessary, escort the patient out of the ED. Inform the patient that you are not able to prescribe or administer the medication they seek, and offer a substitute. When aberrant drug-related behavior is confirmed or suspected in the ED, it should be documented in the chart, stating only the facts. Concerns about opioid overuse can be documented without diagnosing the patient with “drug-seeking behavior, ” which may not be appropriate without evidence of illegal behavior. When physicians are notified by a pharmacist of forged or altered prescriptions, law enforcement authorities should be called, and physicians should cooperate with the legal investigation. The prosecution of fraudulent behaviors, such as using aliases to obtain opioids, requires the involvement of the state bureau of investigation or a similar state agency. SPECIAL CONSIDERATIONS: LEGAL ISSUES The U.S. Drug Enforcement Agency (in addition to state agencies) licenses physicians to administer or dispense controlled substances. However, state law determines most prescribing regulations. Physi cians should be aware of state laws regulating controlled substances prescribed in their practice setting. The prescribing of opioids to a known drug addict could result in restriction of the physician’s medical license in some states, although this is rarely prosecuted for isolated incidents. If a patient refuses to acknowledge an addiction, the physician cannot be held accountable unless medical records at the facility where the patient presents document the addiction. In all states, it is illegal for patients to forge or alter prescriptions. In some states, it is illegal for patients to use aliases or factitious illness to obtain opioids.

e an addiction, the physician cannot be held accountable unless medical records at the facility where the patient presents document the addiction. In all states, it is illegal for patients to forge or alter prescriptions. In some states, it is illegal for patients to use aliases or factitious illness to obtain opioids. Furthermore, in some states, concealing previous or recent prescriptions for opioids when requesting opioids from a new practitioner is illegal. REFERENCES The complete reference list is available online at www.TintinalliEM.com. Tintinalli_Sec05_p0229-0266.indd 266 8/2/19 6:35 PM