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Imaging and the Opioid Crisis

What you need to know about radiologists’ increasing role in the epidemic.

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According to the most recent U.S. data, 33,000 deaths were caused by opioid overdose in 2015.1 The opioid epidemic — including prescription pain relievers, heroin, and synthetic opioids such as fentanyl — is a serious national crisis affecting public health, as well as the social and economic welfare of many relatively young patients and their caregivers.

As with many areas of healthcare, radiology is feeling the impact of the opioid crisis gripping the nation. Radiologists are seeing a dramatic increase in patients coming into emergency departments (EDs) with complications related to substance use disorders of these highly addictive opioids. The skyrocketing numbers present challenges as well as opportunities for radiologists who are on the front lines of the crisis every day, such as Efren J. Flores, MD, a radiologist at Massachusetts General Hospital. In a recent interview with the ACR Bulletin, Flores discussed his work with patients presenting with substance use disorders in the ED.

What is the role of radiology in the opioid crisis?

Radiology is central to patient care, particularly in the emergency setting. We’ve seen a dramatic increase in the past year of patients coming into the ED with complications related to substance use disorders. This patient population is underserved due to many factors, including social stigma and fear of punitive consequences due to their disease. Many of the patients we see as radiologists use the ED as an entry point to get in touch with the healthcare system. By the time we see these patients, they’ve already had more advanced complications because they’re hesitant to ask for help.

In a recent study (bit.ly/Rads_Opioids), we looked at the prevalence and type of complications related to substance use disorders in 1,031 patients arriving at emergency radiology. We found that the mortality rate was 14 percent for patients with a positive imaging diagnosis of substance-use-related complications — significantly higher than the 10-percent rate for patients with no such history.

Radiologists need to collaborate in designing responsive patient care models to support the health and survival of this underserved population. Many patients may start their disease from a prescription related to a medical condition. While radiologists write relatively few prescriptions, a recent JACR® study (bit.ly/IR_Opioids) found that the large majority of those IRs who prescribe medications write for at least one opioid, most commonly hydrocodone with acetaminophen. Education of safe and sound opioid prescription practices for radiologists moving forward, in particular with the development of IR training programs, will be an important step for radiology.

How can radiologists become more familiar with the signs of opioid use disorder?

Emergency radiologists are often the first ones who can diagnose and alert other members of the care team that a patient may be suffering from a substance use disorder. These patients often present to the ED with complications related to skin and soft tissue infections caused by the use of non-sterile needles. In some cases, we find septic emboli in the lung or brain. When these patients start accessing larger or more central veins, they become more prone to these types of infections. Patients may be found to have mycotic arterial aneurysms and infective endocarditis after they present to the ED. As radiologists, we need to keep educating ourselves on the clinical presentation of substance use disorders to increase diagnosis accuracy.

How can radiologists better advocate for this patient population?

Medicine in general, including radiology, has a critical role in this crisis, and we as physicians have to understand that it’s not the patient’s sole responsibility. On many occasions, patients who are genetically predisposed to develop a substance use disorder are initially prescribed opioid medications for pain management of a medical condition and, unfortunately, subsequently develop dependence. Many go from crushing and injecting pills to injecting heroin as a less expensive way to deal with their disease.

Radiologists are in a unique position to see beneath the surface and alert the healthcare team, which is often the first step in the patient’s recovery. We have an opportunity to look beyond the reading room and help patients with their illness.

What resources can radiologists provide to patients?

Radiologists can encourage patients with substance use disorders to use sterile needles, inform them about needle exchange programs, and advise them to use alcohol at the injection site to decrease the risk of developing infections. We can also collaborate with other members of the care team, in particular mental health professionals, to develop outreach efforts and help steer patients into recovery programs or connect them with coaches, both in the hospital and community settings, to help them with their illness. We can provide patient education materials, hospital resources, and substance use clinic information in our waiting rooms. Outreach efforts to assist these patients at every point of contact with the healthcare system will be critical as we continue to support them in recovery and achieving overall better health. Most importantly, we need to have compassion in our interactions with these patients. It’s the first step to getting them on the path to recovery.

ENDNOTE

1. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths- United States, 2010–2015. MMWR Morb Mortal Wkly Rep. 2016;357:1445–1452. Available at bit.ly/Opioid_Report.

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