Your next patient is a 32-year-old woman complaining of a headache. You check her vitals: a heart rate of 101 bpm, blood pressure of 150/90 mm Hg, sat of 100%, respirations of 22 bpm, and a 10/10 on the pain scale. You talk to her about her complaint of headache. She says she is allergic to Tylenol.
The patient is calm, healthy-looking, and in no distress. You do your usual head-to-toe review, and ask your typical history and physical questions. Her neurological exam is negative. She is positive for a wide range of complaints—body aches, crampy back pain, runny nose, slight abdominal pain, maybe some diarrhea, and of course, the headache. You spend minimal time on the other systems, and inquire about her main complaint. Because this patient has a plethora of issues and is of child-bearing age, you check her CBC, BMP, ECG, flu, UA, and hCG. You know they are going to come back negative. You consider a D-dimer because she is on birth control and might be PERC-positive, but you’re not convinced this is PE-related.
What if we start the conversation differently? What if we did an HPI with specific questions? She has been to the ED before, and doesn’t have a primary care physician. Nothing stands out as an emergency. You wonder if a workup is necessary, but don’t want to miss any zebras. A few clues suggest this could be something nefarious, but the opioid epidemic should tell us otherwise.
The bottom line is patients want pain medications. We have to figure out if a patient is drug-seeking or has a valid complaint. The problem is we cannot predict what she has based on a limited history and physical. The answer to this case lies in our bedside manner, approach, and honesty. Opioid abuse, misuse, withdrawal, and addiction are not diagnoses of exclusion; none of us wants all those tests done.
ED visits and overdose deaths involving opioid analgesics and benzodiazepines increased from 0.6 to 1.7 per 100,000 between 2004 and 2011. (Am J Prev Med 2015;49:493.) The number of deaths per year attributed to prescription opioid medications reached 16,651 in 2010. (MMWR 2013;62:234; http://bit.ly/2yM9QfS.)
We don’t ignore the one or two percent risk of certain diagnoses like PE, MI, and aortic dissection, so why ignore the signs of drug-seeking? The abuse of and addiction to opioids is a serious global problem that affects the health, social, and economic welfare of all societies. (National Institutes of Health, 2014; http://bit.ly/2yPhFUg.) Just like we would not forget to ask about smoking or cholesterol levels in a patient with chest pain, we cannot forget to ask about pain medication use.
It is estimated that between 26.4 and 36 million people abuse opioids worldwide. (United Nations Office on Drugs and Crime, 2012; http://bit.ly/2yQcYJU.) An estimated 2.1 million Americans suffered from substance abuse disorders related to prescription opioid pain relievers in 2012, and 467,000 people are addicted to heroin. (Substance Abuse and Mental Health Services Administration, 2013; http://bit.ly/2yRKaAw.) Surely, the smaller percentage of those with PE, MI, or dissection is outweighed by a diagnosis of opioid abuse or withdrawal.
A study in the Western Journal of Emergency Medicine looked at 178 patients from the case management program who made 2,486 visits in one year. (2012;13:416.) Headache accounted for 21.7 percent and back pain 20.8 percent, while requesting a refill took up seven percent, lost or stolen medication 0.6 percent, 10/10 pain 29.1 percent, greater than 10/10 pain 1.8 percent, and out of medication 9.5 percent. Not every headache is going to be a stroke.
Just as we take measures to rule out PE, dissection, and MI by risk-stratifying patients, we should consider an individual’s risk for abuse before prescribing opioids. (Ann Emerg Med 2016;68:S81.) We are behind the times if we do not risk-stratify patients for potential abuse or misuse. Narcotics-seeking is often hidden among the initial investigation. It may even get lost in a triage provider’s initial questions and three to four hours of unnecessary tests. Neither the provider nor the patient really wants to talk about narcotic abuse, but we should be asking our patients flat-out: Do you have a problem with narcotic pain medication use?
Addiction has a strong, visceral hold on our patients, and we are ignoring the easy stuff. Questioning our patients directly about it should not be a game. When all the information is gathered in the initial interview without bias or judgment, patients are more likely to get the treatment they need. This may stop us all from doing unnecessary workups and costly imaging.
Next time we interview a patient, we should ask if he has tried anything for pain and list multiple medications: acetaminophen, ibuprofen, tramadol, morphine, or methadone. Patients may not be upfront about these medications if they have true addiction issues. They are fearful we will not prescribe pain medications or treat their acute pain. When we set the standard of care in the beginning, however, we can avoid drama and overtesting.
We should ask every patient of every age and walk of life about his personal experience with pain and then consider how to address it. This starts with being upfront in a nonjudgmental way and using a team approach to their care. It may prevent thousands of deaths and save hospitals millions of dollars. It will also get patients the help they actually need. The nature of their complaint doesn’t even matter, but our practices can change because of it.
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