He was one of my closest friends growing up. He was super smart, fun and funny, insanely talented musically, very friendly and generous. He opened my ears to beautiful music I’d never heard, my eyes to books I’d never considered reading, and my mind to travel and exploring things beyond my backyard. We spent years hanging out at each others’ houses, joining each others’ families for “family time”, playing music together, looking at glow in the dark stars on the ceiling guessing where we’d be in 10 years. But I haven’t talked to him in about that long. He became a heroin addict within his first year as an undergrad at an Ivy League institution. I tried. He’d say he stopped using, but he was still using. And eventually I got tired of the lying.

How in the hell does a smart and talented guy like that wind up putting needles in his arms? Finally, on one of those occasions when he said he was clean, only to have his father find drugs on him and flush them down the toilet, I asked him that very question. The answer was simple. He had knee surgery his senior year of high school and had been given opiate pain medications in recovery. He’d ask for refills during what he called a prolonged recovery, getting very used to how good the pills made him feel. When the orthopedic surgeon started balking at refilling his prescription (Rx), he found he could get the same feeling (only cheaper, quicker and without negotiating) by buying heroin on the street. By that time he said without the drug, nothing felt as good – not food, not music, not sex. And he was convinced nothing would ever feel as good again without that opiate support of his dopaminergic pathways in his brain. It was that simple.

Last year I read a great novel by my favorite chick-lit author Jennifer Weiner called “All Fall Down” which the New York Times Book Review amusingly called, “Compulsively readable.” Weiner tells the all-too-common story about how quickly and seamlessly a “regular” person can become addicted to opiates. The story about my friend, however, is a true one. Just like this true story of prescription drug abuse that is required reading in some university-level psychology courses that deal with substance use/addiction (published in Real Simple). 

I used to feel like we weren’t part of the problem as emergency physicians. I used to think writing a short-term prescription for Percocet or Vicodin for someone with a chronic pain syndrome just to get them through until they saw their primary care provider “did no harm.” I certainly didn’t think I had a shot at curing an addiction in the emergency department (ED). In addition, during my residency the Joint Commission adopted “Pain” as the sixth vital sign, so I even considered it a part of my job “to relieve pain and suffering” by writing these prescriptions. Add to that a progressively increasing emphasis on patient satisfaction for reimbursement, and in 2012, you’ve got your 259 million opiate Rx, or in other words, “a bottle for every American adult.” Several years into this career, and countless articles later, I am clear on the fact that I was dead wrong; overdose (OD) deaths from prescription opiate medications almost quadrupled from 2000 to 2014. As did heroin OD deaths from 2002-2013 according to the CDC.

Who is “at risk”?

While opiate-related deaths increased for everyone, according to the CDC women are particularly vulnerable:

• Women between the ages of 25 and 54 are more likely than other age groups to go to the emergency department from prescription painkiller misuse or abuse.
• Women ages 45 to 54 have the highest risk of dying from a prescription painkiller overdose.
• Over 48,000 women died of opiate-related deaths between 1999 and 2010

With almost 20,000 OD deaths caused by prescription-opiate medication in 2014 alone, this is an epidemic. The epidemic is still going strong. In 2015, OD deaths continue rising with opiates involved in most cases according to CDC data.  Add to that the 10,000 additional OD deaths caused by heroin in 2014, this is an opiate-driven epidemic right here in the United States. For comparison, the Ebola outbreak in West Africa that began in early 2014 has, to date, claimed 11,316 lives.

Chief Complaint: Rx Refill

Someone asked me a few years ago what was my least favorite case to see in the emergency department. Number one is still “Foreign Body in the Ear” – because it’s always a roach. This led to the longest comment thread I’ve ever been involved with on Facebook. But ask anyone who works in an ED to read the above heading “Chief Complaint: Prescription Refill,” and most will flinch. To deny the prescription to someone who feels they need it takes a long, often uncomfortable if not confrontational conversation (and runs the risk of a poor patient satisfaction survey). To give a prescription takes a few seconds. Most EDs are filled to the gills with patients waiting to be seen. One can see the temptation to write the Rx.

Yesterday the Boston Globe’s Metro section ran a story on investigating the physicians and pharmacists writing and dispensing opiate prescriptions in Massachusetts. Though the Attorney General is looking for illegal activity in the investigation, this data is monitored closely by the DEA and now state-controlled prescription monitoring programs. Following up, today’s Boston Globe reported that 2015 showed an increase in opiate-related deaths in Massachusetts (over 1,100 in the first 9 months), disproportionately affecting young people, age 25-44. The Massachusetts investigation comes a few months after an L.A. physician was convicted of murder in the deaths of three patients related to opiate prescriptions that she wrote, sending a message that physicians are being held responsible for sorting out patients who are addicted and specifically at risk for overdose.

For non-cancer (and similar) and non-acute pain, patients seeking opiates in the ED is problematic. Many emergency departments recognize the role they play in preventing these overdoses, which contribute to the fifth leading cause of potentially preventable death in the US. While the epidemic is being addressed on multiple levels in the public health arena, emergency departments can intervene:

• Institutional Policy – Some ED’s publicize on posters in the waiting room that it is the department’s policy not to refill opiate prescriptions. Others have the policy written in black and white on an institutionalized page that providers can hand to patients.
• Prescription Monitoring Programs like PDMP in Pennsylvania, CURES in California, which allows providers to view Rx dispensed to patients throughout the state. The idea is that only one provider write chronic opiate prescriptions. It is a requirement where I work to check this database everyone we prescribe opiates. 
• Surgeon General’s Pocket Guide to prescribing for chronic pain 
• American College of Emergency Physicians (ACEP) Professional Organizational Guidelines and Policies

So when an ED doc does not write an opiate prescription for chronic pain, it’s not to be mean. It is, in a real way, to save lives.