Opioid Addiction: Clinicians Roles

I deeply appreciate any conversation about our role in putting a wrench in the gears of this monstrous epidemic of prescription drug abuse. That said, I'd like to submit to the discussion that I'm actually quite tired of hearing about overdoses and deaths. While it's terrible that people are dying because of this, the actual mortality rates associated with opiate dependence is extremely low when compared to the overall toll taken on these individuals' lives and welfare. The vast majority of people addicted to opiates survive, but only in the midst of tremendous wreckage and brokenness. I don't need to tell you about the plight of these people. They lose their jobs, they lose their kids, they lose spouses and family. They grieve. Their behavior turns erratic and they hate themselves. They are driven to depression and despair, and then even more erratic and self-destructive behavior. Their skin turns sallow, their eyes hollow, they become pale. We all know "the look." They contract other diseases. These ancillary phenomena, which can't easily be calculated into a nicely rounded mortality statistic, are of much more concern to me than the few who actually die. I'm concerned about the kids whose opiate-addicted fathers turn into pathetic couch creatures, and whose mothers turn into absentees and truants. I'm concerned about people who used to be mechanics and teachers and nurses and truck drivers, serving society and living functionally, who are now turned into chimeric pseudo-humans, always bloodhounding after a drug or a sensation or simply to calm their screaming mu-receptor neurons.

While I don't think this is news to anyone at all, I at least want to submit this more robustly into the conversation. To be perfectly frank, the average person is not all that concerned if people they perceive to be worthless drug addicts wind up accidentally killing themselves, and so an overemphasis on the mortality rate associated with narcotics is not likely to yield you widespread or impassioned support. If instead you focus on the carnage of the broken lives of those who are still very much alive with their addiction, then you may actually solicit more concern and more action.

I do appreciate the increasing role I see emergency physicians playing in our public health, and this is clearly an enormous realm requiring aggressive intervention.

In 2012 our ED introduced a pain and addiction strategy to address concerns regarding prescription drug misuse and to help patients living with persistent pain break their cycle of ED use. For those who were not ready to attend a pain self management program or addiction treatment program a comprehensive care plan was developed to ensure consistency in the department. It was surprising how quickly ED visits stopped but more importantly how some who were open to treatment got the help needed. We published our experience in JEN, Nov 2014 (pg 552-559) as well as CJRM Feb 2014 (27-30).

Despite how busy we are we need to be willing to hear their stories and remind ourselves that individuals living with addiction are often GOOD PEOPLE making BAD CHOICES. Maureen

Discussion in my rural medical community is about the unintended consequences of changing Hydrocodone to a schedule II drug. Specialists who are 80-150 miles away are prescribing much larger amounts to offset the inconvenience to their patients if refills are needed. The large amounts are sitting in people's medicine cabinets readily available to teens and others who might be interested in them.

72% of kids in the Canadian Drug Monitoring Survey of 2011 stated that their first exposure to an opioids came from their parents medicine cabinet. Only 6% report their first opioid exposure from their peers. 90% of all addiction will manifest before the age of 35 years of age. (National Centre on Addiction and Substance Abuse at Columbia University) Our youth are most vulnerable to the re-wiring effects opioids have on nervous system function. How we prescribe opioids to kids should be different then how we prescribe to a 50 year old who has no history of addiction. Addiction is a Pediatric illness that carries on into adulthood.

Just wanted to add a useful link to a Youtube video on this issue. I use it in my clinical practice to help patients make the needed shift in both opioid use and how they are living and managing their chronic pain. It's put out by the Australian Pain Society (Yes Mel, the Australians are much further ahead then the rest of use in dealing with this issue.)

"Brainman stops his opioids" and "Brainman understands pain in less than 5 minutes" Enjoy.

A thought:
Does the availability of Naloxone actually INCREASE the risk of OD? Will people with addictions take more meds to get more effects because they have a safety plan in place?
This is parallel to the observation made on a previous EMRap episode in which the commentator's sons got bicycle helmets and promptly head butted each other because they were protected by the helmets.
Maybe the suggestion of a safety net increases the risky behavior???
Outcomes would be nice, but not very likely to get them in this arena.

This is so great! I am so happy to hear this segment on EMRap-- thank you both.

We also started a take-home naloxone program at several of our hospitals in RI which is combined with consultation with a peer recovery coach for referral to treatment. There is also a similar program at Boston Medical Center.

re: Ronald's comment about overdose rates and naloxone, there have actually been numerous studies about community distribution of naloxone, which have NOT shown an increased risk of OD, but actually increased engagement in treatment services. The ED programs are very new, so studies about outcomes from ED programs aren't out quite yet but definitely needed.

Taking away the Press-Ganey survey about "did the doctor adequately treat your pain", and not linking said survey results to reimbursement (Worst. Idea. EVER), as well as adjusting people's expectations about never being in any discomfort at all from anything, and that sometimes it's not gonna be possible to have zero pain, are also important steps to decreasing opiate prescribing in the ED. Better coordination of care on a system wide level so chronic pain patients are not using the ED for their medications will help. In our community we are working on better communication between primary care and ED docs and use of controlled substance contracts. What really needs to happen in our state are better resources for substance abuse or dependence treatment, and more pain management specialists/education.