Pain, Compassion, Addiction, Malingering: How To Use Opioids (and how to not use opioids)

Lecture is 35 minutes, then questions for 20 minutes. On Vimeo.


Opioids are extraordinary agents that have been used for millennia for the relief of pain and suffering; however, the history of opioids is also one of abuse and addiction. In the US, we are in the midst of a devastating iatrogenic chapter in this history, a prescription opioid epidemic that kills 15,000 Americans per year by overdose and destroys hundreds of thousands of lives and families.

In this presentation we will consider the magnitude and consequences of the current epidemic; describe how clinical organizations and clinicians were appropriated by the pharmaceutical industry so that Americans–5% of the world’s population–consume more prescription opioids than the rest of the world combined; and discuss strategies for managing patients who present to emergency departments with acute or chronic pain complaints that account for our competing mandates to palliate and protect.

These strategies center on an assessment of the likelihood that using opioids will deliver benefit or cause harm. For patients at low risk to be harmed by opioids, utilize aggressive multimodal analgesia, including opioids as needed to control acute pain, and prescribe optimal outpatient non-opioid analgesia with a small number of breakthrough opioids if indicated. For patients at high risk to be harmed by opioids, including patients with chronic pain and patients with flags for opioid misuse, avoid using opioids in the ED and outpatient settings, utilize non-opioids to manage symptoms, and, when misuse is suspected, nudge the patient to addiction treatment. The goals of optimal opioid stewardship are to provide effective symptom relief while preventing de novo cases of addiction, to control the supply of opioids in the community, and to protect existing addicts from further harm while promoting recovery.

For slides, the HELPCard treatment referral business card, and phraseology to use when managing patients at risk for opioid misuse, go to

PulmCrit Alcohol withdrawal protocol / Outpatient Alcohol Detox (Librium Chlordiazepoxide) / Dryden Non-Agonist Outpatient Opiate Withdrawal Meds



Outpatient alcohol withdrawal management, per ARCA protocol.

Naltrexone 50 mg tabs: half tab on first day then 1 tab daily after eating, Disp x 30

CDZ 25 mg tabs:  1 tab q6h x 2 days, then 1 tab q8h x 2 days, then 1 tab q12h x 2 days, then 1 tab daily x 2 days. Dispense x20.

Folic Acid (B9) 1 mg tabs: 1 tab daily, Disp x 14

Thiamine (B1) 100 mg tabs: 1 tab daily, Disp x 14

Carbamazepine 200 mg tabs: 1 tab q12h, Disp x 14 (7 days)


from Asplund 2004

Dryden Outpatient Opiate Withdrawal Rx 2011

Discharging Inebriates