Thoughts Concerning the Opioid Crisis from an Emergency Physician

By Daniel Stevens, DO

I know that everyone has been watching the news and the coverage of the Opioid Crisis. There is a big push right now to decrease the use, abuse and prescribing of opiate-like medications. I have heard two streams of thought about pain medication prescribing during my years as a doctor: one for increased prescribing and one for less. I remember in the past discussing hearsay about doctors being sued for failing to treat pain adequately. I also know about “pill mill” clinics and the way that they abuse their prescribing power for monetary gain. I have also seen prescribers withhold treatment for fear of “making that patient an addict”.

When I was in residency, I remember being told that if I didn’t treat everyone’s pain, I wasn’t doing my job fully. The 5th vital sign, the pain scale of 1-10, was hailed and celebrated as very helpful in adequately assessing the state of pain in a patient. Now that I have been practicing for a time, I have my own opinion about the 5th vital sign. I think most ER doctors would agree that many of their ER patients state that their pain is a 10/10 as they are smiling at you, texting on their phone and eating a bag of chips that they were able to buy from the vending machine before entering the room.

I must state the obvious: drug addiction is horrible! It takes lives, destroys lives and only leads to misery. Everyone I know has had to deal with drug addiction in their lives one way or another. Either by seeing family or friends becoming addicted and the destruction it does, or becoming addicted themselves. I also realize that something has to be done, and I do feel that many of the new rules and regulations will decrease addicts’ access to prescription medications.

Many of the proposals will help us to combat addiction at the front line, but I do have some questions concerning potential, unintentional, negative impacts the new rules and regulations might bring about. What do we do about the elderly person on pain medication with chronic arthritis who can get up every day and brush their hair without pain or the middle aged worker with degenerative disk disease who is able to go to work because his pain is treated? How will the new laws and guidelines affect their lives and ability to obtain treatment for their painful conditions?

I believe that heroin and other illicit drug use will increase. I think the related illicit drug deaths and crime associated with it is going to skyrocket even more than it has already. Medicine has been focused on treating pain for so long, what will happen when we quickly take patients off pain meds? Addicts are going to get their fix one way or another, and many will now go straight to the drug dealer’s house. The other side of that coin is that people stay addicted to opioid medications, and I don’t want that either, so what do we do? I’m not sure, but many agree that we need to increase the number of rehab centers, introduce other medical treatments and decrease costs associated with them. Going to rehab can be very expensive, not only due to the cost of rehab, but also the costs associated with not working, being away from family, social stigma, etc. Household bills still need to be paid even if someone is in treatment.

One of the proposals I have heard many times is that only pain management doctors should treat pain. While I agree with this for patients who need large doses of pain meds, I don’t feel all patients with chronic pain should be sent to them. Many patients where I practice can barely make it to their primary provider’s office for refills, mainly because they don’t have insurance, access to transportation or extra finances. To now tell them that they are going to have to see two doctors, one for conditions like hypertension or diabetes and another for pain meds, puts undue burden on them.

One last thought: what about the increased pressure on us as doctors and medical providers? Will we now be asked, “Why didn’t you treat his pain adequately?” or, “why did you give the patient that drug?” Will more time-consuming paperwork be added on top of the already overly burdensome, non-medical, wasteful, essentially meaningless paperwork and charting just so we will be able to give prescriptions to patients that need them and get paid for the office visit? I mean, we all know that doctors have a very easy schedule, are never under a lot of stress, are always playing golf and have perfect lives.

I don’t have the answers to the Opioid Crisis, but I do try to be fair with my patients concerning pain medications and other controlled substances. I write these types of medications when I think they have significant pain, but try to limit the number given. I also try other avenues of medications before going straight to opiates. I always discuss with them that I am not the type of doctor that writes pain meds for just anything, and the patients seem to understand me better when I tell them this. I’ve been in the same location now for some time, and the local population seems to know that just because they come to the ER with a complaint doesn’t mean that they get a prescription, but will always get my care.

Editors note: The government mandated pain scales and adequate treatment of pain, which helped start this mess. Emergency medicine doctors rarely prescribe more than 10 to 12 pills whereas private physicians are prescribing 30 day supplies, so we are not the major problem. It is in our nature to treat pain, since that is what most patients go to an emergency department for. Insurance companies will pay for opioid pain medications but do not cover non-opioid pain medications such as lidocaine patches, gabapentin, etc. This has to change.