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

2. 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

3. 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

4. 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

5. 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

6. PA Prescription Drug Monitoring Program (PDMP)
52 clicks to check the PDMP
Without patient consent, BTW
20 clicks to prescribe oxycodone

7. ED Dilemma #2
Warm and hard handoffs

10. 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

11. 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…

12. 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

13. Ethical Dilemma #4
Naloxone

14. 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)