A Complicated Clinical Question: Radiology’s Role in the Opioid Crisis
Radiologists can assist in diagnosing opioid-related conditions and support pain management following image-guided procedures
From the mid 1980s until the early 2000s, several policy briefs published by health organizations, such as the World Health Organization (WHO), encouraged physicians to treat patient pain more aggressively. Concurrently, drug companies developed powerful new painkillers to meet increasing demand, and oversight in the prescription of narcotics was scaled back.
These well-intended efforts to more aggressively treat pain have contributed greatly to the current opioid crisis.
Furthermore, there is evidence that the COVID-19 pandemic has worsened the crisis. The 2020 World Drug Report indicates that in the U.S. and Canada, fentanyl-related deaths increased by roughly 50% in only one year.
As addictions to and abuse of prescription and illicit opioids are increasing, emergency department radiologists are increasingly facing the task of examining patients who present with opioid-related complications. Radiology plays an important role by offering diagnostic and treatment guidance to clinicians and specialists, exercising caution when prescribing opioids, and participating in research efforts.
‘The Edge of the Film’
In emergency rooms, patients who abuse opioids may present with loss of consciousness, altered mental status, or with no available clinical history.
Mariza O. Clement, MD, MSE, section chief of Emergency Radiology and assistant professor of radiology at Boston University School of Medicine, said that imaging is the first and quickest line of defense to detect problems and advise next steps in the treatment journey.
“When these patients initially present to the emergency room, they often have vague symptomatology or they can’t even communicate because of their level of impairment,” Dr. Clement explained. “Imaging is instantly available to determine the underlying pathology for the patient. We serve as that critical triage point of determining how the patient is going to be managed.”
Anna Bader, MD, MS, assistant professor of radiology and biomedical imaging and section chief for thoracic radiology at Yale School of Medicine, New Haven, CT, added that there are classic imaging findings of opioid abuse, such as septic emboli of the lungs, but that it’s important to keep in mind that opioids also have whole-body effects.
“Aside from typical findings, there’s also what we can find at ‘the edge of the film.’ These are the things that are not expected,” Dr. Bader said. “From a clinical and educational perspective, I emphasize that radiologists should look everywhere, because there are a whole host of other complications that may be happening.”
Opioid abuse can affect several organ systems, and common complications include abscesses, cellulitis, disseminated infections that reach vital organs or bones, pseudoaneurysms, or even needle fragments lodged in soft tissues.
Being familiar with how these complications appear on imaging is key, as some of them are emergent or may not be apparent during a physical exam, according to Joseph Mansour, MD, thoracic radiologist and assistant professor of clinical radiology & imaging sciences at Indiana University School of Medicine, Indianapolis.
“Some of these complications could be life threatening, such as pseudoaneurysms that can rupture,” Dr. Mansour said. Some are also difficult to detect on a physical exam, especially if they’re in deep structures, like the abdomen or pelvis.”
Dr. Clement explained that CT is the imaging modality of choice for detecting these complications.
“The most common complications of opioid abuse are readily apparent on CT. It’s also accessible and fast, and it doesn’t have many contraindications,” she said.
Dr. Mansour added that point-of-care US can also be helpful for clinicians, and that MRI is the preferred modality for investigating more specific questions.
“Our clinical colleagues can scan patients with portable ultrasound devices, which provide very useful information for differentiating between pseudoaneurysms and abscesses, for example. MRI is very helpful to troubleshoot specific concerns, like infection of the bone or spine,” Dr. Mansour said.
Outside the scope of diagnosis for those using opioids, radiologists may also be called to provide imaging for patients who may be suspected of transportation of illicit drugs by concealment within the body. Body packers may ingest dozens of packets containing life-threatening doses of opioids or other illegal drugs. These smugglers may then present to physicians for evaluation while in legal custody because of drug-induced toxic effects or obstruction or perforation of the gastrointestinal tract.
While there is no standard for imaging patients suspected of body packing, CT has been used for packet detection and unenhanced CT without bowel preparation is a reliable technique for detection of ingested foreign bodies.
"When these patients initially present to the emergency room, they often have vague symptomatology or they can’t even communicate because of their level of impairment. Imaging is instantly available to determine the underlying pathology for the patient. We serve as that critical triage point of determining how the patient is going to be managed.”
MARIZA O. CLEMENT, MD, MSE
A Thoughtful Approach to Pain Management in the IR Suite
In the interventional radiology (IR) suite, it’s crucial for radiologists prescribing drugs for postprocedural pain to minimize the risk of opioid dependency by taking a thorough clinical history. When formulating pain management plans for their patients, interventional radiologist should be aware of any risk factors that may predispose patients to substance use disorder, commented Jason C. Hoffmann, MD, vascular and interventional radiologist and associate professor in the Department of Radiology at NYU Long Island School of Medicine.
“In interventional radiology, it’s important to sit down with our patients before a procedure and understand more than just what their initial problem is, but what their history is,” he explained. “There is a pretty wide and diverse list of risk factors that we need to be aware of. Spending time with our patients during the initial inpatient consultation or outpatient IR clinic visit can help us to better understand our patients’ histories, comorbidities and risk factors, allowing us to develop thoughtful, patient-specific pain management strategies.”
When prescribing for pain management, Dr. Hoffmann recommends multimodal approaches that utilize nonopioid and nonpharmacological pain relief.
“Using things like rest, ice, acupuncture, relaxation techniques or image-guided nerve blocks, as well as non-steroidal anti-inflammatory drugs in combination with minimal opioids will often treat pain better than opioids alone,” he said.
Multidisciplinary, Interinstitutional Research on Opioid Abuse
In 2019, the Penn PET Addiction Center of Excellence (PACE) was established with funding from the National Institute on Drug Abuse.
PACE is a joint endeavor between the University of Pennsylvania’s Radiology and Psychiatry Departments, and Yale University’s PET Center. PACE’s goal is to act as a resource for researchers of opioid use disorders (OUD), enabling them to obtain the preliminary data needed to seek NIH grants for further research.
“There are many important neurochemical mechanisms of OUD that need to be studied, and PET is the only technique that enables a clear view of what’s occurring at the neurochemical level in the brain,” said Robert H. Mach, PhD, professor of radiology, director of the PET Radiochemistry Program at the University of Pennsylvania, and co-principal investigator of PACE.
Therefore, PACE is utilizing novel imaging technologies in its research, including the Penn PET Explorer, a PET scanner that simultaneously scans both the brain and body.
“To really understand what is going on in OUD, one needs to study the mechanisms not only in the brain, but in the brainstem and spinal cord to see how they adapt over time. And that’s what the Penn PET Explorer enables us to do: We see the brain, the spinal cord, and other organs. We’re able to look at what OUD does not just in the brain, but how it affects the entire body,” Dr. Mach said.
Dr. Mach stressed that going forward, joint research efforts like PACE will become more common in solving complex, multidisciplinary problems like the opioid crisis.
“We work together with our colleagues at Yale on a very complicated clinical question, enabling us to make important observations,” he said. “That’s really the direction science is going now, to put together strategic teams with strengths in various areas that work together to answer these questions.”
For More Information
Read previous RSNA News articles on opioids and imaging: