In the low acuity section of any emergency department in the country there are many patients presenting with chronic pain, most commonly back pain, knee pain, hip pain. Many patients where unwittingly steered away from actively engaging their pain with exercise, rehabilitation, and self-motivation towards a passive approach that promotes a sense of helplessness and reliance on medications. Opioids play right into this dynamic and in some patients promote passivity, increasing disability and overall worsening in function.
Interestingly, smoking is a powerful risk factor for developing chronic pain. The mechanisms are complex and discussed in detail in the article by Shi et al below, but the association is clear. In my practice I found putting a clear boundary on the amount face-to-face time I spent discussing opioid scripts with my patients opened up time to spend discussing issues I know are truly of benefit to them like smoking cessation and exercise.
JAMA recently published an article by Elbert et al. ( also below) on a the success of varenicline in helping patients quit smoking. Given the evidence and increasing options available to us, smoking cessation should be considered a core component of any initiative to improve emergency department treatment of pain and promote rational use of opioids in chronic pain.