• Avoid giving a short-acting opioid in the ED. Injections of short-acting opioids can lead to acceleration of tolerance and create institutional dependency, worsening catastrophizing. There is no upside to this practice. If patients who take opioids for chronic pain have a new pathology requiring additional opioids, the best approach is a PCA pump that is locked—inadequate pain relief in these situations increases risk of abuse in previously stable patients.
• Do not prescribe opioids at discharge. Patients on long-term opioids have an identified primary prescriber and should have their opioids prescribed only by that provider. They should not receive a prescription to “hold them over” until they see their caregiver; they would receive the identical response from their primary prescriber if they presented before their scheduled appointment and asked for additional opioids. Several guidelines suggest that if you do choose to provide opioids at discharge, it should be a dose with which you are comfortable in a quantity that suffices until the next business day. Even if this option is chosen, it should never be repeated a second time.
• Make use of any existing state drug database. This is the only practical way to identify double doctoring and dates of prescriptions. This has had a dramatic effect on physicians’ ability to identify patients seeking additional prescriptions and allows for a “level playing field” in the discussion with patients.

Avoid Labelling Patients or Turning Them Away

Patients with addiction disorders have a medical condition requiring care, just as do alcoholics and smokers. It is part of our mandate to identify this condition and offer support. Patients who use drugs intravenously are at high risk for serious infections; addicts are always at risk for overdose or acute withdrawal. Placing signs in the waiting room advising patients that opioid prescriptions are not renewed not only breaches EMTALA regulations but risks turning away very sick patients (with an addiction disorder) who feel they will not be cared for. It also encourages patients in severe pain to leave without receiving care.

Patients with an addiction disorder are not immune to painful conditions. They are not mutually exclusive. Identifying patients as addicts or “drug seeking” often precludes any further consideration of comorbidity. Addiction is but one medical condition, just as is diabetes, and does not prevent the presence of a second illness. To the contrary, they are more at risk because of their primary condition.