A test positive for cocaine is a true positive for that drug—and no patients testing positive for cocaine should receive opioids. Patients stating they have a prescription for an opioid but who test negative for that opioid should raise concern about diversion.

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ACEP Now: Vol 33 – No 05 – May 2014

Last time, we explored the research and statistics on pain management and opioid addiction (ACEP Now March, p. 22). In this column, we will explore some standard strategies to use when patients seek opioids in the ED.

In the management of chronic non-cancer pain (CNCP), the current recommendation is to use “universal precautions” for all patients. Just as we assume in the ED that any patient might have a blood-borne pathogen and so we take universal precautions, the baseline assumption in chronic pain is that anyone can be at risk for diversion or addiction. This does not mean that no patients receive an opioid for pain care; rather, it means that a standardized approach is used for all patients. This type of approach can be used in the ED.

A 37-year-old male presents at 2 am on a Saturday complaining of dental pain and insisting on getting some “Percs” for his pain. What to do?

• Offer a valid alternative. Dental pain can be severe, and it cannot tell time. During working hours, such patients can get to a dentist, but such service is not available in the middle of the night. Rates of addiction are higher, and there is no way to test objectively for pain. To ensure pain is addressed while also allaying any concerns over diversion, the best option is to offer a dental block with bupivacaine. The anesthetic will last six to eight hours and allow patients to see a dentist in the morning; it is a valid analgesic approach to opioids. You should raise, in a nonconfrontational manner, your suspicions of nonmedical use of opioids with any patients who refuse such therapy and offer to provide support for substance abuse if they admit to that problem. Invalidated concerns of misuse do not mean no management of pain; they mean that the pain should be properly managed with alternatives to opioids. Do not allow patients to suffer because of our (unjustified) suspicions.
• Establish the risk of abuse or diversion. The Opioid Risk Tool is an excellent screening tool for establishing risk of abuse and can be done in one to two minutes. Low-risk patients have less than 0.2 percent risk of abuse.
• Consider a urine drug screen. While urine drug screening has many limitations in assessing patients with psychiatric disorders or with altered mental status, it can be of value in patients seeking opioids. A test positive for cocaine is a true positive for that drug—and no patients testing positive for cocaine should receive opioids. Patients stating they have a prescription for an opioid but who test negative for that opioid should raise concern about diversion. Further discussion is required before any consideration of opioids for such patients.

A 44-year-old woman with 10 years of low-back pain and who states she takes a sustained-release morphine preparation (and has done so for four years) comes to the ED saying she has “run out” and needs some pills for the next three days until her doctor gets back in town.