Opioid Crisis Misconceptions and Unintended Consequences

Peter Salgo, MD: I am going to ask one more question about the so-called gateway drug issue. That’s a strange term. Are prescription opioids gateway drugs to illegal opioids?

Jeffrey Bratberg, PharmD, FAPhA: I think homelessness, poverty, and deficiencies in employment are gateway structural determinants of health; 80% of health is determined by those very things, and there are all kinds of other layers on top of that. I do not like the term “gateway drug.” I think that people have dopamine deficiency, and I think that poverty enhances that. Poverty is caused by many things, and so if substances are available, or prescribed appropriately or even inappropriately, they are going to change that dopamine level. People are then not going to be using that opioid to achieve dopamine sufficiency, but to avoid withdrawal, and they do not have the access to achieve safety beyond that.

Peter Salgo, MD: I am going to introduce one of my least favorite phrases that I’ve heard for a long time. I recognized it was horrific even when I was house officer—“drug-seeking behavior.” If you do not like somebody, if you do not like what that person is saying to you, if that person may not be like you, and that person needs medicine for pain, these people get called drug seekers. And immediately a wall comes down, and that is it. They are not going to get what they need, and they suffer. Language is important, isn’t it?

Jeffrey Bratberg, PharmD, FAPhA: Language is essential, and I think the other important thing to think about here is the emotional pain of trauma. I have a student who was in a horrific accident and injured his hand. He may have been on opioids, but I know that he has trauma, and I do not know whether his medical care had been adjusted considering that. He is a 20-year-old pharmacy student. I’m concerned about that, about how are we addressing that issue. Dr Lynch, that’s not something to address in the emergency department. I do not know how you address those cases, then.

Joshua Lynch, DO, EMT-P, FAAEM, FACEP: This relates back to the point regarding practitioners being seemingly afraid to prescribe opioids, which is an unintended consequence of labeling this as an opioid crisis. I do not think that it is not a crisis, but causing this fear or transition away from prescribing opioids, when 5 or 10 years ago we would have routinely and appropriately prescribed opioids, has had a negative effect. We have seen many patients come to the emergency department after very painful—whether they have had oral surgery or other kinds of procedures as an outpatient—and their pain is not adequately treated due to a variety of reasons, which puts us in an interesting position. Do we, as emergency department physicians, as a third party, start opioids on somebody who did not get them from the specialists? Oftentimes, we will try to do our best to control pain there. But it is an interesting phenomenon, one that I do not think was intended. 

Theresa Mallick-Searle, MS, RN-BC, ANP-BC: It is another failing that we have in health care: this whole work-up and assumption now throughout the community that opiates are inherently bad. There are not only health care providers themselves who need appropriate pain management, but their patients too, and both groups are so fearful about getting addicted that they are not getting their pain adequately managed. There is a huge education piece that is missing, which hopefully we are going to address today.

Charles Argoff, MD: Dr Lynch, you may remember that, and it may be still true for you, we’re in the same state…emergency department doctors were exempt from looking at the prescription monitoring program of New York, so there was an almost built-in lack of need to look at a safeguard. We could make this into a safer process. Dr Adler has already said this, but we could do a risk assessment. Would a doctor give an NSAID [nonsteroidal anti-inflammatory drug] to somebody with an active, bleeding ulcer? No. We would ask about that. We can create a safer approach to pain management and one that we monitor carefully. It is not one and done, not a process where we merely say, “Here is your prescription, go away.”

When New York state started its prescription monitoring program—it may still be in effect—we did not even have to look at a prescription monitoring program. You were exempt from that, which is crazy.

Transcript Edited for Clarity