Emergency Doctors First Line of Defense Against Opioid Addiction
A recent New England Journal of Medicine study suggests that too many cases of opioid addiction start with a short-term prescription obtained at an ER visit.
Jared Friedman, MD, Clinical Vice President, Emergency Medical Service Line, Avera Health
MED: ER physicians often see the fallout of opioid addiction. Do you think we have a problem in our area?
Dr. Friedman: Unfortunately, yes, and we will likely continue to see the effects of it. It is not as bad here as it is in other places, but even one life lost to addiction is a tragedy. It is one of the reasons for last year’s legislation that equipped first responders in our region with naloxone. Now, pharmacies can also counsel people and offer naloxone.
MED: This study suggests that addiction often starts with an ER visit. Why do you think that is?
Dr. Friedman: CMS called pain “the fifth vital sign” and said we have to address it. So I think the pendulum swung to treating all and every pain. Now, we have to swing back. Part of that is managing patient expectations about tolerable and manageable pain. They have to understand that it isn’t realistic to expect to leave the ER with no pain at all.
MED: Most of the patients that come into the ER are strangers to you. How do you decide when to write a prescription for an opiate?
Dr. Friedman: There is no objective test to determine whether a patient does or doesn’t have pain. We try to evaluate the patient and look at all of their risk factors. People with certain psychological diagnoses or other addictions are at higher risk for becoming addicted if we prescribe an opioid drug. It also depends on the type of pain. Treatment of acute patin is different from chronic pain. For chronic pain, opioids are not effective.
In addition, we try to use non opioid agents or patches, or even home remedies like icing and elevating whenever possible. If all other alternatives have been tried or are ineffective, then we may prescribe an opioid but only for a short period of time.
MED: What is being done here to help reduce the risks for opioid addiction among Avera patients?
Dr. Friedman: An ad hoc subcommittee of the SD State Medical Association has developed best practices for prescribing of opioids for noncancerous pain. We have taken that a step further to develop a standardized chronic pain management contract. They goes into their medical record, so if they come into my ED, I can see that and have a discussion with them.
Another thing that helps is the prescription drug monitoring program accessible through the state Board of Pharmacy. This is helpful in drug diversion because I can log in and see if a patient has had an opioid prescription recently.
According to the American College of Emergency Physicians, pain is the most common reason patients come into the ER and ER physicians see more patients in acute pain than in almost any other medical setting.