The opioid epidemic has claimed hundreds of thousands of American lives over the last twenty years. Provisional data from 2017 estimates the death toll from prescription and illicit opioid use to be nearly 50,000, and opioid overdose deaths were five times higher in 2016 than 1999.
Sadly, the devastation shows no sign of slowing. How did we get to this point?
What Medical Professionals Thought They Knew about Opioids
Dr. Pete Mikkelsen, the Medical Director of Emergency Services, believes the ball began to roll in 1980 with a letter to the editor in the New England Journal of Medicine which minimized the risk of addiction from doses of opioids.
“If you were administered a few doses of morphine after a surgery, you were relatively unlikely to develop an opioid addiction. However, what happened with that letter is that it was used to advocate opioids for chronic pain,” states Dr. Mikkelsen. “Large pharmaceutical companies started to promote the use of long-acting opioids to treat chronic pain, and that ultimately led to the difficulties with addiction we see today.”
Compounding the issue was the introduction of pain as the “fifth vital sign” in an effort to evaluate patients, whether acute or chronic. The problem is, pain is subjective—unlike pulse, blood pressure, or temperature.
“Because we were asking individuals to self-report their level of pain, it was implied we would do something about it,” explains Dr. Mikkelsen. “A lot of people feel that further promoted the use of opioids; specifically prescription opioids.”
Emergency Departments: Managing Patient Expectations
In Dr. Mikkelsen’s opinion, emergency medicine departments have stepped up to try to address the problem from a chronic pain management perspective, by educating the population about the true role of emergency physicians and the emergency department.
“Certainly, there is a role for prescribing opioids for acute injuries and other medical conditions, but the management of chronic pain within the emergency department is really something we try to avoid,” states Dr. Mikkelsen. “Instead, we prefer pain to be managed through primary care offices or pain specialists, thus limiting the number of prescriptions the emergency department dispenses.”
Many states follow a prescription monitoring program where physicians are able to see any prescriptions filled by patients for controlled substances. This helps emergency physicians understand if patients are going to multiple providers.
Signs of Opioid Addiction & Overdose
While the number of opioid-related deaths is startling, it is just a fraction of those struggling with opioid addiction. “When seeing patients in the emergency department who we're concerned may be misusing opioids, we really need to start viewing that as a disease and not just a problem,” explains Dr. Mikkelsen. “We need to move people towards treatment options to help them overcome their disease.”
Warning signs to watch for include loved ones not acting themselves, such as withdrawing from social, occupational, or recreational activities or inability to meet daily responsibilities. Those battling addiction may defend their drug use and become angry if they’re met with questions about it.
More severe—and critical—are warning signs of an overdose. Opioids depress the respiratory drive, which leads to a cascade of events, including death. “If someone isn’t responsive, especially if he’s salivating and presenting small pupils, that could indicate an opioid overdose,” advises Dr. Mikkelsen. “There may be pill bottles or needles present, or other signs of injecting opioids on the arms or other places on the body as well.”
Opioid Overdose Reversal Agents
Many experts are now recommending that family members and friends of individuals with opioid use disorder or opioid addiction have access to a reversal agent such as naloxone (most often recognized as the brand name Narcan®). The availability of these medications varies from state to state, with some allowing simple over-the-counter access and other states requiring a prescription.
Recognizing that the epidemic isn’t going away anytime soon, Dr. Mikkelsen encourages friends and family members to be aware of the potential risk. “There's the treatment aspect of seeking help for opioid use disorder. The other consideration is being prepared for overdose,” he explains. “When encountering someone who has potentially overdosed, you have the opportunity to save a life by providing the Narcan in addition to calling 9-1-1.”