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Letter to the Editor: Opioids and Objective Pain

doi: 10.1097/01.EEM.0000515699.44086.69
Letter to the Editor

Editor:

Certainly, there is a national opioid addiction crisis (but no evidence that the use of opioids in the emergency department plays a significant role), and the issue of opioids in frequent flyers with chronic subjective complaints (headache, back pain, tooth pain) has been an ongoing and serious ED problem.

I am concerned that the opioid-lite approach that Dr. Graham Walker wrote about and that is being applied in some EDs will inadequately treat the non-addict with an acute, objective pain condition. (“The Opioid-Lite Emergency Department,” EMN 2016;38[12]:1; http://bit.ly/2jg21u1.)

Why would you treat a patient with bona-fide renal colic from a kidney stone with non-opioids? Are there data that once a person with kidney stones gets relief from an opioid with an NSAID that they will become addicted? The strength of evidence for lidocaine is small; IVF may actually worsen pain. What is the point, other than a badge of honor, that you are a “wall” and give no opioids?

And for fractures and significant acute, objective soft-tissue injury, the data for muscle relaxers are very limited. Almost all the studies with gabapentin were falsified and only FDA-approved for true diabetic neuropathy. Steroids are contraindicated for back pain. Magnesium for migraine has poor data. And lidocaine patches are unaffordable.

If Dr. Walker is a “huge fan” of opioids, why would he want to take the best thing we have for acute, objective injury and replace it with less effective and more expensive meds? We should not confuse this population of normal people with acute objective pain given opioids in the ED and a small script for home with chronic subjective frequent flyers or with our national opioid addiction crisis. These are three distinct and likely unrelated topics.

Mark Mosley, MD, MPH

Wichita, KS

Dr. Walker responds: Thanks for writing. I certainly hope that readers would not misunderstand my interview with Dr. Alexis LaPietra; I assumed starting each column with “No ER can or should function without opiates. I'm a huge fan of opiates,” and “I still use opiates, frequently. This is not an opiate-free ED” would have made that abundantly clear.

To Dr. Mosley's point: I try to address patients' pain quickly and appropriately. Do I start with Toradol for renal colic? Absolutely; a summary of a 2004 BMJ systematic review of renal colic suggests, “NSAIDs achieve slightly better pain relief, reduce need for rescue analgesia, and produce much less vomiting than do opioids.” (2004;328[7453]:1401.) If that doesn't work, do I give opiates? You're damn right I do. (I typically use the “1+1” Dilaudid protocol.) (Ann Emerg Med 2009;54[2]:221.) Are there other alternatives that may work as well, like IV lidocaine? Yes, there probably are. I'd think if anyone likes to have lots of weapons in their armamentarium, it's emergency physicians.

If you can't get a shoulder reduced using your favorite technique, should you be opposed to learning a new method that may work, even if you mostly stick to your tried-and-true approach? I should hope not.

Where did our “national opioid addiction crisis” come from? We have met the enemy, and it is us.

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