HR: What are we seeing right now in emergency departments around the country when it comes to the opioid epidemic?

DS: EDs are on the front lines, and no ED has been spared the impacts of opioid use disorder. In many parts of the country, they've seen a significant rise in visits from this disorder.

How did we get here? Many factors came into play: one factor was the public health focus on pain, around 2011. An Institute of Medicine report cited a need for clinicians to be more vigilant in the assessment of pain and more aggressive in the treatment of pain.

But as the focus heightened around pain management across all practices in medicine, there was a quadrupling of opioid prescriptions. Illicit drug abuse followed with scaling of street sale of these potent opioids; we now have a significant public health crisis.

In fact, one reason the ED PECS survey has been delayed in implementation and deployment is due to industry concern related to pain questions. Many worry that scoring providers on pain management themes creates pressure to prescribe so that patients will rate care highly.

We certainly don't want incentives that are misaligned to prudent care quality. Also, there was "unlinking" of HCAHPS pain domain scores from value-based purchasing calculations that determine a portion of risk-withhold reimbursement from patient perception of care.

HR: Is it realistic to think we can really address this epidemic in the ED, given our constraints?

DS: As Albert Einstein famously said, "Insanity is doing the same thing over and over and expecting a different result." Clearly, the global approach to pain and combatting this crisis needs to change.

From a provider and staff standpoint, drug seeker interactions can pose a real challenge, creating workplace stress that contributes to burnout. Balancing a positive interaction but not giving in to demands for drugs that would be unsafe and unwarranted can be tough even for the seasoned communicator and empathic clinician.

Engagement of all key stakeholders (from the federal government, system and group leadership, providers and staff and patients) will be imperative. From educating local communities and using treatment resources wisely to creating effective and sustainable solutions and monitoring progress, it will take all hands on deck to course-correct the trajectory on this profound epidemic.

HR: What is the role of leaders here?

DS: It's the job of executives and department leaders to understand the impact of this epidemic from the clinician and staff perspective and to support sound and prudent approaches to pain management. By developing and implementing a systemwide chronic pain policy, for example, we can ensure a consistent approach to treating pain.

Leaders need to understand the local, state and federal policy and programs that can engage stakeholders in the community. Also, it's important to identify and avail key resources that help frontline providers. In this way, patients can receive the multi-modal treatment necessary to overcome an opioid

use disorder.

HR: So what can providers do who may face challenging situations like a suspected drug seeker?

DS: Patient communication can change the course of the visit. When you introduce yourself, acknowledge the patient's pain, complete a good history and exam, and demonstrate empathy, you shift the interaction to a more positive one.

The patient will be more likely to be receptive to your explanation of why you won't be utilizing opioids as part of the treatment regimen. Also, it's important to communicate that you want to help them and that you do have something to offer while remaining within the bounds of safe and prudent care guidelines.

Some key words that are helpful include: "I know you're in pain, and I'm going to help you get this under control just as safely and prudently as I can." Or:

"I'm sorry you are in pain like this all the time. I can help reduce your pain today." Or even: "Please understand that making you safely comfortable is one of my priorities."

HR: Any last thoughts?

DS: As providers, we need to proactively engage patients we meet who may be at potential risk for addiction and abuse of opioids. I'd recommend the clinical team align on standardized approaches to acute and chronic pain treatment. And then, don't be afraid to reach out and have a conversation with a patient you're concerned about. You could save a life.