Opioids and the Emergency Physician: Ducking Between Pendulum Swings

In the late 1980s, undertreated pain became a focus of many clinicians, investigators, and industry. We coined a term, oligoanalgesia, to embolden earlier, titrated opioids and other analgesic use. Regulators mandated pain assessments and actions as a part of health care facility credentialing, and the prescribing of opioids increased yearly from 1990 to 2010. We now sit amid another opioid epidemic with death and disability. Many know of the patterns of use and abuse near the turn of the 20th century when opium was a new agent; this triggered opioid regulations and control, notably, the US Harrison Narcotics Tax Act of 1914 criminalizing nonmedical use. Despite regulation of opioids, swings upward in medical and nonmedical use exist in recent modern times. For example, a 1959 Readers Digest article noted a current opioid addiction crisis, reminding us that the cycles reappear often, with varying frequency, responses, and consequences. The current opioid upswing is rooted in prescribed and illicit use, the latter including heroin (or other “street” opioids) and diversion of another’s or factitious gain of a prescribed opioid. The widespread increase in opioid use correlates with increased overdose deaths and deaths in all segments, including more affluent and suburban or rural groups, not just in an inner-city or isolated population. Although the peak of the current wave crested in approximately 2010, we retain a large group with this affliction. This triggered calls for regulation and control in many facets of opioid deployment, including emergency care, despite few data suggesting a clear link between emergency department (ED) opioid use and later harm. Some seek governmental ED dose restrictions, and others call for “an opioid-free ED.” The goal of these calls to action is good: to avoid opioid harm, notably, death. At the