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Letter to the Editor

Limiting Opioids is Correct and Humane

doi: 10.1097/01.EEM.0000553486.55048.a5
Letter to the Editor
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I am writing in response to Dr. Mark Mosley's editorial, “Humane and Correct Treatment for Pain.” (EMN 2018;40[11]:6; http://bit.ly/2P1ZbJj.) He said those who start managing pain in the ED with a nonopioid approach and who espouse the view “I usually don't write opioid prescriptions, but when I do, I never write for more than 12” are irrational. I have not written a prescription for oxycodone since 2001 nor for narcotics since 2015.

I was first trained in anesthesia, and I was amazed and shocked by the amount of opioid prescriptions my EM colleagues gave out. As an anesthesiologist, I was taught that oxycodone was an extremely addictive medicine reserved for the worst pain, such as cancer, and that more forgiving opioids such as hydrocodone or Tramadol were less addictive in short-term use. Although plenty of people are addicted to the latter two, many addicts and addiction centers reported the preference of oxycodone to hydrocodone or tramadol. I was always reluctant to hand them out. I recall attending an EM conference about 20 years ago where one of the speakers (a pharmacist) decried that the EM community was “feeding the beast” by prescribing oxycodone instead of less addictive medications.

That said, I agree with Dr. Mosley about treating acute pain in the ED reasonably and without prejudice. If a patient presents with an acutely painful condition, I will not hesitate to order opioids initially or in addition to other analgesics. I do not see, however, what is irrational about not prescribing addictive medications to someone I do not know, will not follow up with, on whom I must now perform a CAPE assessment in addition to everything else I must do, and then hope he will not become addicted.

Countless addicts have told me their path to addiction started with a simple script for Percocet. Would CAPE have predicted addiction in these otherwise functional, opioid-naive nonaddicts without psychiatric issues? Is it not reasonable to prescribe a cocktail of analgesics, using opioids as rescue agents only? I challenge Dr. Mosley's rationality assessment and ask if our opioid-prescribing practices over the past decades have been rational and humane.

Is adding another task and assessment to the already overburdened EP humane? Dr. Mosley suggests a system that will produce different results for different people and subject the assessors to accusations of bias and discrimination against those who claim CAPE is incorrect v. a universal policy of no or limited opioids in the ED and connecting those patients with appropriate outpatient medical follow-up.

Maybe I am irrational, but it seems I am in good company.

Al O. Giwa, MD, MBA

New York City

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