A test positive for cocaine is a true positive for that drug—and no patients testing positive for cocaine should receive opioids. Patients stating they have a prescription for an opioid but who test negative for that opioid should raise concern about diversion.
Last time, we explored the research and statistics on pain management and opioid addiction (ACEP Now March, p. 22). In this column, we will explore some standard strategies to use when patients seek opioids in the ED.
In the management of chronic non-cancer pain (CNCP), the current recommendation is to use “universal precautions” for all patients. Just as we assume in the ED that any patient might have a blood-borne pathogen and so we take universal precautions, the baseline assumption in chronic pain is that anyone can be at risk for diversion or addiction. This does not mean that no patients receive an opioid for pain care; rather, it means that a standardized approach is used for all patients. This type of approach can be used in the ED.
A 37-year-old male presents at 2 am on a Saturday complaining of dental pain and insisting on getting some “Percs” for his pain. What to do?
- Offer a valid alternative. Dental pain can be severe, and it cannot tell time. During working hours, such patients can get to a dentist, but such service is not available in the middle of the night. Rates of addiction are higher, and there is no way to test objectively for pain. To ensure pain is addressed while also allaying any concerns over diversion, the best option is to offer a dental block with bupivacaine. The anesthetic will last six to eight hours and allow patients to see a dentist in the morning; it is a valid analgesic approach to opioids. You should raise, in a nonconfrontational manner, your suspicions of nonmedical use of opioids with any patients who refuse such therapy and offer to provide support for substance abuse if they admit to that problem. Invalidated concerns of misuse do not mean no management of pain; they mean that the pain should be properly managed with alternatives to opioids. Do not allow patients to suffer because of our (unjustified) suspicions.
- Establish the risk of abuse or diversion. The Opioid Risk Tool is an excellent screening tool for establishing risk of abuse and can be done in one to two minutes. Low-risk patients have less than 0.2 percent risk of abuse.
- Consider a urine drug screen. While urine drug screening has many limitations in assessing patients with psychiatric disorders or with altered mental status, it can be of value in patients seeking opioids. A test positive for cocaine is a true positive for that drug—and no patients testing positive for cocaine should receive opioids. Patients stating they have a prescription for an opioid but who test negative for that opioid should raise concern about diversion. Further discussion is required before any consideration of opioids for such patients.
A 44-year-old woman with 10 years of low-back pain and who states she takes a sustained-release morphine preparation (and has done so for four years) comes to the ED saying she has “run out” and needs some pills for the next three days until her doctor gets back in town.
- 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.
A Final Suggestion
Most people with personality disorders have less refined interpersonal social skills. They succeed in getting what they want through more obvious manipulation, such as overpraising or creating feelings of guilt or anger. Every physician has to recognize that such feelings are not normal during a patient encounter and should be recognized for what they are: manipulation by the patient. Rather than reacting to those emotions, the physician should recognize them as a sign of a personality disorder and respond accordingly with no emotional responses and the establishment of limits for that encounter. A typical response could be: “I understand that you say you are in a lot of pain. I am going to do everything I can to help you get that pain under control now and after discharge. What I am not able to do, however, is provide opioids for this particular situation. I am certain that we will still be able to take steps to get your pain better controlled.”
Dr. Ducharme is editor in chief of the Canadian Journal of Emergency Medicine, clinical professor of medicine at McMaster University, and chief medical officer of McKesson Canada.