For context I am a new EM attending and really struggling with the current management of chronic pain patients in my hospital system. More specifically we have a group of patients with sickle cell disease who are in the ED daily and have pain plans with 3-4 mg dilaudid q1H. If they still have pain after 3 doses they get admitted on a PCA dilaudid pump. I have see many of them leave AMA when their PCA is turned off and represent to the ED wanting another round of Q1H doses. On labs their retic count isn’t elevated, no infection/O2 requirement or their objective findings of crisis. I’ve talked with my medical director and peers and a lot of us feel they are needing the ED more and more frequently is opioid withdrawal pain as opposed to sickle cell crisis. Whenever we have any other opioid seeking patients even with other very painful conditions like endometriosis, fibromyalgia, arthritis etc we don’t give them multiple rounds of IV opioids without question. I feel like I’m harming patients by worsening their opioid addiction and exposing them to infections by constantly accessing a port and having them be in the ED daily for their ‘fix’. Most of these patients are becoming more and more violent if you have this honest conversation with them. Our inpatient teams don’t want to admit them because they have assaulted staff for discontinuing their PCA or trying to discharge them.
Would love to hear from other specialists about how you are managing this in your system? How would I go about having a conversation with heme/onc and other disciplines involved?