Addiction and the ED: Ethical Dilemmas Michael A. Turturro MD, FACEP

Pain is the most common reason patients come to the ED 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

I wish I could admit you to the detox unit but… 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)