Best Case Ever 41 Opiate Misuse and Physician Compassion

Opiate misuse is everywhere.

Approximately 15-20% of ED patients in the US are prescribed outpatient opiates upon discharge. In Ontario, about 10 people die accidentally from prescription opiates every week. Between 1990 and 2010, drug overdose deaths in the US increased by almost four fold, eclipsing the rate of death from motor vehicle collisions in 2009. This was driven by deaths related to prescription opiates, which now kill more people than heroin and cocaine combined. Opiates are the most prescribed class of medication in the US. In 2010, one out of every eight deaths among persons aged 25 to 34 years was opiate-related. Four out of 5 new heroin users report that their initial drug was a prescription opiate. In Ontario, three times the people died from opiate overdose than from HIV in 2011.

Yet, we are expected to treat pain aggressively in the ED.

Dr. Reuben Strayer, the brains behind the fantastic blog EM Updates tells his Best Case Ever, in which he realizes the importance of physician compassion in emergency management of pediatric seizuresapproaching the challenging drug seekers and malingerers that we manage in the ED on a regular basis.


This Best Case Ever is in anticipation of an upcoming main episode in which Dr. Strayer and toxicologist Dr. David Juurlink discuss how to strike a balance between managing pain effectively and providing the seed for perpetuating a drug addiction or feeding a pre-existing drug addiction, and how we best take care of our patients who we suspect might have a drug misuse problem.

Published October, 2015

The Opiod Risk Tool

opiod risk toolReferences

Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6(6):432-42.

Baumblatt JA, et al. High-risk use by patients prescribed opioids for pain and its role in overdose deaths. JAMA Intern Med. 2014 May;174(5):796-801.

Bridget M, Kuehn MSJ. SAMHSA: Pain Medication Abuse a Common Path to Heroin Experts Say This Pattern Likely Driving Heroin Resurgence. JAMA. 2013;310(14):1433-1434.

FOAMed Resources

Dr. Mike Evans’ video on Best Advice for People Taking Opiod Medications

Reuben Strayer’s take home points from his talk at SMACC Chicago 2015 on EM Updates

Dr. Helman & Dr. Strayer have no conflicts of interest to declare

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About the Author:

Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.


  1. Rory Stuart, MD October 13, 2015 at 11:31 pm - Reply

    I had the opportunity to hear Dr. Strayer speak at SMACC Chicago last spring. I really appreciated his take on the compassionate treatment of opioid addiction in the ED. It seems like so often when dealing with these, at times difficult, patients we beat around the bush and never really address their addiction. We give reasons why we can’t or won’t refill their meds- typically punting them back to their PCPs or surgeons. We tell them that we can’t find a reason to admit them or find a clear cause of their pain, all the while willfully ignoring the issue of their underlying addiction. These interactions always left me feeling somewhat like a fraud, these people were clearly suffering but I was doing nothing for them. After listening to Dr. Strayer at SMACC I’ve taken to addressing the problem head-on. I tell them that the opioids are actually making their pain worse. I try and get social work to give them as much information as possible about the relatively scant community resources that are available. I think many of us are hesitant to have these talks because we don’t want to be dragged into an argument about discharge prescriptions, but I’ll tell you what… many of these patients are open to the discussion and actually seem appreciative that I’m taking the time to address their addiction and not just blowing them off as a “seeker”. What I need, and I’m sure I’m not alone, are more reliable and accessible outpatient addiction referral options.
    Thanks for the great post!

    • Anton Helman October 13, 2015 at 11:47 pm - Reply

      Thanks for the thoughtful comments Rory. Yes, Dr. Strayer has spent an enormous amount of time and energy educating himself on this important topic and it showed in his spectacular talk at SMACC. Our hope, in the upcoming episode, is to provide listeners with some tools to help them to start addressing these issues with confidence. Even if you simply get the patient to start thinking about how to better manage their addiction, you have helped them make the first step to recovery. Patients are often at rock bottom when they visit the ED, and we have a chance to turn their lives around by a simple, quick intervention. There are a number of toll free numbers that patients can call for ongoing opiod addiction management. You can print a card to give your patients with a help number on it from EM Updates

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