How emergency physicians can minimize stress, avoid confrontations while meeting patient needs

Drug Diversion and Abuse Is a Major Societal Problem

In 2012, an estimated 23.9 million Americans age 12 or older—or 9.2 percent of the population—had used an illicit drug or abused a psychotherapeutic medication (such as a pain reliever, stimulant, or tranquilizer) in the past month. Marijuana is the gateway drug. Despite being declared by many to be a benign recreational drug, the odds of going on to addictive drugs such as opioids or methamphetamine are 140 times greater for those having used marijuana than having not used it. Despite the publicity of the rise in misuse of prescription opioids, the 25 percent increase in marijuana use since 2007 is the largest increase for any category of drugs of abuse. Nevertheless, prescription opioids are now fourth behind marijuana, alcohol, and cigarettes in prevalence of abuse among adolescents. They rank second behind marijuana in terms of rate of abuse in society. Given their much greater risk of morbidity and mortality, as well as the association with organized crime, the growing misuse of prescription opioids has created ever-increasing concern.

Chronic Non-Cancer Pain Management Is Failing Miserably

It is the complex disease state with the highest prevalence in society, has the highest economic impact on the workforce, and results in poverty-level existence for the average family that has someone suffering from it. Unable to pay for the multidisciplinary care required, more than 90 percent of patients with chronic non-cancer pain (CNCP) receive inadequate care for their pain. Lacking any other resource, many CNCP patients turn to the ED. This specific issue was addressed in the previous article, “Why Us? The Role of Emergency Physicians in the Care of Chronic Pain” (ACEP Now, January 2014).

Oligoanalgesia Rampant Across Health Care

Education in medical schools about pain management is less than one-third of similar training in veterinary schools. There is even less education about addiction and how to interact with people suffering from personality disorders. The average physician enters practice undereducated and ill-equipped to deal with any of the very difficult situations described above. The natural reaction to this lack of preparation is to be defensive and overly suspicious and find encounters with patients seeking opioids to be emotional and stressful. It’s hoped this article can provide some suggestions about a rational approach to such patients to minimize that stress and avoid confrontations while meeting patient needs.

Distinguishing People in Pain Seeking Opioids from People Seeking Opioids for Addiction or Diversion

Patients with pain as their primary complaint represent up to 75–80 percent of emergency patients. After 7 p.m., up to 70 percent of motor vehicle collisions are related to alcohol use. Similarly, the prevalence of patients with addiction as a medical disorder rises in patients presenting to the ED after 7 p.m. Even in inner-city hospitals at night, the ratio of patients in pain to those with addiction or diversion issues remains greater than three-to-one. The age of the patient is not of value; people visiting the ED for opioid abuse come from all age groups, including young children (Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2009).