Pain leads to suffering. Opioid misuse leads to suffering.

We strive to avoid both for our patients.

On the one hand, treating pain is one of the most important things we do in emergency medicine to help our patients and we need to be aggressive in getting our patients' pain under control in a timely, effective, sustained and safe fashion. This was the emphasis 10-20 years ago after studies showed that we were poor at managing pain and our patients were suffering. On the other hand, opioid dependence, addiction, abuse and misuse are an enormous public health issue. Opioid misuse in Emergency Medicine has become a major problem in North America over the past 10 years at least partly as a reaction to the years that we were being told that we were failing at pain management. As Dr. Reuben Strayer said in his SMACC talk on the topic:
“Opioid misuse explodes in our face on nearly every shift, splattering the entire department with pain and suffering, and addiction and malingering and cursing and threats and hospital security, and miosis and apnea and naloxone and cardiac arrest.”
So how do we strike a balance between managing pain effectively and providing the seed for perpetuating a drug addiction or feeding a pre-existing drug addiction? How do we best take care of our patients who you suspect might have an opiod misuse problem? To help us sort through this difficult conundrum we have Dr. David Juurlink, a toxicologist and Dr. Reuben Strayer an EM physician, who both a special interest in opioid misuse.

 

Written Summary & blog post prepared by Keerat Grewal, edited by Anton Helman, December 2015

Here are some numbers that may surprise you:

In a recent ED study on opioid prescribing patterns in Annals of EM, 17% of patients in the US were prescribed opioids on discharge from EDs. In Ontario, about 10 people die accidentally from prescription opioids every week. Between 1990 and 2010, drug overdose deaths in the US increased by almost four fold, eclipsing the rate of death from motor vehicle collisions in 2009. This was driven by deaths related to prescription opioids, which now kill more people than heroin and cocaine combined. Opioids are the most prescribed class of medication in the US. In 2010, one out of every eight deaths among persons aged 25 to 34 years was opioid-related. Four out of 5 new heroin users report that their initial drug was a prescription opioid. In Ontario, three times the people died from opiate overdose than from HIV in 2011.

Fig 1: Opioid sales, admissions, and deaths in the U.S.
 
Who is at risk for Opioid Misuse in Emergency Medicine?
All ED patients are at risk for opiod misuse, regardless of their risk factors. Even opioid-naive patients with no risk factors for opioid misuse are at risk for developing opioid misuse problems.

Nonetheless, their are particular risk factors, red and yellow flags that should raise your suspicion for pre-existing opioid misuse and help guide management. (see Figure 2 and 3)
Patients at particularly high risk for opioid misuse include:

* Young age (< 40 years old)
* Psychiatric history
* Substance abuse history
* Benzodiazepine use

 

Fig 2: Red & Yellow Flags for Opioid Misuse
(courtesy of Dr. R. Strayer)

Fig 3: Risk Stratification for Opioid Misuse
(courtesy of Dr. R. Strayer)

Trajectories of Opioid Use in Emergency Medicine