Viewpoint: Hiding Behind Bad Science and the ‘Opioid Crisis’ : Emergency Medicine News

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Viewpoint

Viewpoint

Hiding Behind Bad Science and the ‘Opioid Crisis’

Mosley, Mark MD

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doi: 10.1097/01.EEM.0000520591.88836.0b
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    We hear about the “opioid crisis” from media outlets, politicians, medical journals, and even conversations in the public square every day. We react with immediate alarm, and rush to begin national and regional programs with opioid-free EDs or opioid-lite EDs, which attempt not to prescribe opioids for headaches, kidney stones, back pain, tooth pain, and other types of chronic pain.

    But have we done our due diligence to the science about this crisis, the same science we demand for all other common aspects of emergency medicine? Or are we simply reacting emotionally to this current political hot button?

    Do we even know what an “opioid epidemic” means? I believe we do not. Like most aspects of science, simplifying this message into a sound bite about the opioid crisis in America may miss essential nuances, and may even completely misrepresent the truth. Several layers of the opioid crisis must be carefully dissected for us to form a reasonable response. Opioids include heroin, methadone, fentanyl, morphine, and oxycodone, and much of the hydrocodone and oxycodone implicated in the opioid epidemic is made and sold illegally (diverted).

    When we hear about various reports of “rapidly increasing numbers of opioid deaths,” we all need to ask, “Which opioids?” and “How were they obtained?” Heroin is the primary offender. Fentanyl made illicitly in China, benzodiazepines sold illicitly, and other illicitly made synthetic opioids are the main culprits in these “opioid deaths.” (Natl Vital Stat Rep 2016;65[10]:1.)

    Let's contrast this reality with average emergency physicians. We do not prescribe heroin, methadone, morphine, or fentanyl. We are not illegally producing or illegally selling hydrocodone and oxycodone prescriptions. When we write hydrocodone- and oxycodone-type prescriptions, we write for small amounts.

    Here is what no one has told you about the so-called opioid crisis: The number of deaths from oxycodone and hydrocodone overdoses actually went down five percent from 2010 to 2015. (NCHS Data Brief 2017;[273]:1.) There was a decrease in 2012, no change in 2013, and an increase in 2014, but overall it's a decrease. (MMWR Morb Mortal Wkly Rep 2016;64[50-51]:1378.) These numbers include illicitly produced hydrocodone and oxycodone. Something else you may not have heard: If the toxicology report shows any hydrocodone or oxycodone metabolites in addition to fentanyl derivatives, all substances found are counted as the cause of death. This very likely over-represents deaths due to hydrocodone and oxycodone. In my state, Kansas, all opioid deaths have decreased, according to the most recent data. (MMWR Morb Mortal Wkly Rep 2016;65[5051]:1445.)

    We in the ED should still be careful when prescribing hydrocodone and oxycodone, especially for the chronic pain frequent flyer. But we should not hijack the political climate of the “opioid crisis” to give us more backbone to confront this essentially unrelated complex and difficult situation of frequent flyers in the ED.

    Scripts of legally made and sold hydrocodone and oxycodone prescribed in small amounts from the ED have nothing or almost nothing to do with the opioid crisis. It simply defies common logic to insinuate that normal patients in the ED with broken bones, kidney stones, or significant musculoskeletal trauma who get IV opioids in the ED and a small script for Lortab or Percocet get a taste of the devil and ultimately die from injecting heroin or benzodiazepines laced with illegally made fentanyl derivatives. I'm sure you've seen an article that said average Joe's life of opioid addiction began with a visit to the ED, but this is a complete misrepresentation of the scientific data.

    It is not simply obliquely opportunistic to use the emotion of “the opioid crisis” to fortify the establishment of opioid-lite EDs; it can be malignant and really bad medicine to deny giving medications that more adequately relieve suffering in certain situations. Ask any emergency physician over 40 when you could not give opioids to a person with an acute abdomen until the surgeon examined him, could not give analgesia to very young children because their pain receptors were not yet developed, or could give only 1-2 mg morphine to the screaming trauma patient because you did not want to mask the symptoms. The opioid-lite ED is a throwback to a time when we hid behind bad science to refuse opioids.

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