Ethical Dilemmas in Managing Addiction at the Emergency Department
Pain management in the Emergency Department (ED) poses ethical challenges due to the opioid crisis. While opioids are effective, concerns arise regarding patients with a history of abuse. The introduction of new opioid legislation and the use of Prescription Drug Monitoring Programs (PDMP) aim to address these dilemmas. Warm handoff processes for substance use disorder treatment present additional complexities in patient care.
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ADDICTION AND THE ED: ETHICAL DILEMMAS Michael A. Turturro MD, FACEP
ED DILEMMA #1 Pain is the most common reason patients come to the ED
The Opioid Crisis Drug OD the #1 cause of accidental death in the US ~ 50,000 total, >30,000 from opioids 80% of new heroin users start with prescription opioids But: 1.1% of opioid addiction attributable to ED exposure
Analgesia in the ED: Realities While alternatives exist, opioids remain the most effective treatment for pain Sometimes, patients with a history of opioid abuse need treatment with an opioid analgesic Is the opioid-free ED a good idea? Is it ethically appropriate to withhold opioid analgesics in patients with objectively painful conditions but a history of abuse? People with legitimate needs go to the ED when they have nowhere else to go Depriving and creating barriers is associated with under treatment Primum non nocere
New Opioid Legislation Limits all opioid prescriptions from the ED to a 7 day supply Refills prohibited from the ED Mandates use of the PDMP Written informed consent when prescribing to minors Pending PA opioid legislation: 67 bills currently under consideration
PA Prescription Drug Monitoring Program (PDMP) 52 clicks to check the PDMP Without patient consent, BTW 20 clicks to prescribe oxycodone
ED DILEMMA #2 Warm and hard handoffs
PA Warm Handoff Process Order in EMR ED staff contacts D&A assessor Warm handoff to SUD treatment Notify PCP through robust discharge notes If patient refuses Discharge with Naloxone medication and naloxone Rx
ED DILEMMA #3 I wish I could admit you to the detox unit but
Medically Managed Detoxification at UPMC Mercy 18 beds No other unit in Allegheny County How many patients present daily requesting detoxification? How many of these patients can get into treatment programs elsewhere? Frustration for patients, families and providers
ETHICAL DILEMMA #4 Naloxone
Naloxone We can t dispense a naloxone to go kit to patients we d have to eat that cost Hospital Pharmacy Director As a law enforcement officer, I have a real problem giving this stuff to criminals they ll wake up and become violent and now they are my problem I m not a medical person, if I wanted to be an EMT I d be an EMT plus all I m doing is encouraging their drug use Police Union President (not from around here)
