As healthcare providers, one of our primary obligations is to relieve suffering. Often, this comes in the form of effectively managing a patient’s pain through the use of analgesics. In recent years, an increased in the use of opioid prescriptions to manage pain has resulted in nothing short of an epidemic: seventy-five percent of deaths related to pharmaceutical overdoses are now attributed to opiate use [1].

When considering an opiate prescription, physicians have to carefully consider the complexities of the medical, social, and psychological aspects of each case in addition to effectively communicating concerns, risks, and expectations to patients. Additionally, providers have to find a way to uphold their obligation to protect patients from the harms of opioid misuse while still heeding the pressure to meet patient satisfaction and care goals. Taken together, prescribing opiates for pain management becomes a serious challenge.

Because of the multifaceted nature of this topic, this month’s case scratches the surface of the issues involved with prescribing opioids to patients in the emergency department setting. It asks readers to explore how they assess a patient’s potential for misuse and harm with opioids in addition to how they negotiate these concerns in their partnerships with patients. While the purpose of this case is to explore the patient education and communication component of opioid prescribing practices, these skills are undeniably linked to the current culture of opiate use and an awareness of best clinical practices. For a comprehensive introduction to the broader scope of this conversation, take a look at the recent ALiEM RP discussion of the Opioid Prescription Epidemic and don’t forget to peruse through the other great FOAM resources assembled there.

The Series

Inspired by the highly successful MEdIC series , What Do You Say? is a case study series that explores difficult patient education scenarios when communication matters most. Every other month, a hypothetical case will be posted with questions for discussion. After a week of community input, relevant experts will provide insight for the community to consider and a curated review of the discussion with expert opinions will be disseminated. Have a difficult patient education scenario that you think would make a great case? Contact me via the contact page or send a tweet to @skobner .

The Case

Dr. Ponder was enjoying his shift in his ED’s “Fast Track” wing, where patients with less serious complaints are generally sent. Over several hours, Dr. Ponder had seen about a dozen cases of pharyngitis, two small lacerations, a pretty bad looking Colles’ fracture, and one patient who was having kidney complaints that should have never been triaged to Fast Track in the first place. I’ll have to bring that up at the next department meeting, he thought.

As he finished typing a note, Dr. Ponder noticed a new patient on the board–a 38-year-old Mr. Wilson complaining of back pain. He signed his chart, printed discharge instructions for the 12-year-old girl in room 4 with pharyngitis, and headed to see Mr. Wilson.

When Dr. Ponder opened the door to the exam room, he found Mr. Wilson sitting upright on the edge of the bed. He wore scuffed Timberland work boots, which were untied with the tongues hanging out. His jeans had several stains and faded lines with tares near the knees and thighs. A few inches of hairy abdomen peaked out beneath his 1997 Jeff Gordon Championship T-shirt, which fit tight throughout his chest. Mr. Wilson’s uncombed hair covered his ears, and his lower face was carpeted by a few days of stubble.

Mr. Wilson told Dr. Ponder that he came to the ED for help controlling his chronic back pain, as he pointed to his lumbar spine. He explained how the pain started some years ago when he was working as a firefighter, and now it comes nearly every day—some days worse than others. He said he normally takes 2-4 pills (400-800 mg) of ibuprofen to control the pain, but today was especially worse. Mr. Wilson stated that in the past, doctors have needed to give him oxycodone to ease the pain when it got this severe.

In completing the rest of the history and physical, Dr. Ponder excluded any recent trauma or inciting cause for Mr. Wilson’s breakthrough back pain. Mr. Wilson also denied any urinary or GI complaints, and only reported a history of depression, for which he sees a psychologist regularly. Dr. Ponder also learned that Mr. Wilson is currently unemployed and lives in a nearby town with some friends. He is a ½ pack per day smoker and drinks 5-6 times a week, sometimes drinking an entire six pack in one sitting when watching NASCAR or football. He denies any illicit drug use or taking any medications besides Ibuprofen.

Dr. Ponder finds Mr. Wilson’s back is visually unremarkable on examination; however, Mr. Wilson winces with light palpation anywhere on his lumbar back. There are no step-offs, or obvious deformities to his spine. He has no difficulty ambulating, and he has no limitation in his range of motion. The rest of his exam is completely normal.

Dr. Ponder tells Mr. Wilson he wants to look over some of his previous charts and call his primary care doctor to see if there could be anything else going on. Back at his workstation, Dr. Ponder finds no record of Mr. Wilson at the hospital and cannot find a contact for Mr. Wilson’s primary care physician. He does a search of his state’s Prescription Monitoring Program and learns that Mr. Wilson received a 2-week supply of Oxycodone from an ED a few towns over three days ago. He also notices a similar opioid prescription, from a different ED, from 11 days ago.

With this new information, Dr. Ponders goes back to the exam room.

“So, can you help me Doc?” asks Mr. Wilson.

If you were Dr. Ponder, What Do You Say?

Questions for Discussion:

  1. How do you determine if Mr. Wilson is a good candidate for an opioid prescription? If your state has guidelines, what are they? If your state does not, what factors do you consider when making your decision?
  1. How do you express your decision to give or withhold opiates to Mr. Wilson? If you are concerned he might be abusing his medication, how do you approach this topic with the patient? What interventions or follow up do you provide?
  1. If you were to prescribe an opioid to a patient, how would you educate them about the risks of opioid use? What information about misuse, addiction, and safety would you include? What follow up do you provide?

Next Week

Come back for a curated community commentary of the discussion as well as two expert responses to the case provided by:

Dr. Lauren Whiteside

Expert 1

Lauren Whiteside, MD, MS

Dr. Whiteside is an Acting Instructor of emergency medicine at the University of Washington. She completed a research fellowship at the National Institute on Alcohol Abuse and Alcoholism (NIAAA T32), Substance Abuse Division, and has a continued research interest in opioid abuse.

Dr. Maryann Mazer-Amirshahi

Expert 2

Maryann Mazer-Amirshahi, PharmD, MD, MPH

Dr. Mazer-Amirshahi is an emergency medicine physician and medical toxicologist at MedStar Washington Hospital Center. She has conducted extensive research on prescription drug abuse, medication reconciliation, patient adherence, and drug shortages.

Discuss the case in the comments section below or by tweeting with #WDYS

  1. Jones CM, Mack KA, Paulozzi LJ. Pharmaceutical overdose deaths, United States, 2010. JAMA. 2013;309(7):657-9. PMID: 23423407