I put that idea to a personal test this month. On my way to the gym on Sunday, October 11, at about 5:50 a.m., I stopped to help a woman get clear of her burning car on the highway. A hit-and-run driver struck me as we headed for the shoulder. She did fine.

The tally: a broken medial malleolus and a broken fibula in my left leg, an ankle laceration of about 15 cm that tore the tibial artery, two broken ribs, and about 40% of my blood volume lost, which brought in the trauma team. No surgery. The wound was closed. Work has continued without a missed day, but standing for long periods is still off the table, so my procedure load has been lighter. Update, October 26: I am at full function again, and my procedure load is back to normal.

In the emergency room, opioids were offered to me repeatedly. Each time I declined. The reasons are the point of this article.

Why does the first opioid exposure matter so much?

Because nobody sets out to become a long-term user. The road usually starts at a sensible prescription for a real injury, and that first episode quietly sets the odds for what follows. Four studies show where the odds come from, and each one names who was studied.

• How many days the first supply covers. Among commercially insured, cancer-free adults who were new to opioids, every added day in the first episode raised the probability of long-term use. The steepest climbs came after day 5 and day 31, after a second prescription, once cumulative exposure hit 700 MME (morphine milligram equivalents), and with first supplies of 10 or 30 days.
• Who happens to be on shift. In Medicare patients who had not used opioids and came through the emergency department, high-intensity physicians prescribed opioids at 24.1% of visits against 7.3% for low-intensity colleagues in the same hospital. Patients who drew a high-intensity prescriber had an adjusted odds ratio of 1.30 for long-term use over the following year.
• Whether the bottle gets filled. Among opioid-naive emergency patients with acute pain, filling an opioid prescription carried 1.8 times the adjusted odds of recurrent use at one year. A prescription that was written but never filled carried no significant increase.
• The person, not the operation. After minor and major surgery alike, 5.9% to 6.5% of opioid-naive adults aged 18 to 64 developed new persistent use, against 0.4% in a comparison group that had no operation. Smoking, alcohol or drug use disorders, mood disorders, anxiety, and pain that predated the operation predicted it. The size of the surgery did not.

Read the four together and a pattern shows up. The injury decides how much it hurts. The first exposure, and the terrain it lands on, decide the long-term risk. Minor operations and major ones carried similar rates of persistent use, which tells you the drug was meeting the patient, not the incision.

Why did I say no in the emergency room?

Two reasons, both personal. First, an initial exposure is the doorway to chronic use, and minimizing that initial dose is worth the trouble. I would rather not predispose my nervous system to a medicine that I might not need down the line.

Second, I was not feeling much pain. My endorphins and epinephrine were high. The body keeps its own emergency analgesia, a descending system from the brainstem to the spinal cord that runs on endogenous opioids and related messengers, and its strength varies greatly between people. Mine was working hard that morning, so an opioid would have been treating pain I mostly did not have.

What can carry the pain instead of an opioid?

For the first couple of days I relied on ibuprofen and acetaminophen, plus two kinds of electrical stimulation (TENS for nerves, EMS for muscle), a spot vibration plate and infrared light therapy. Distractive tools, I call the physical ones: they hand the nerves something else to report. I’m not trying to be woo-woo. Our clinic offers each one: laser therapy, vibration therapy, TENS therapy and a home TENS unit to take home.

The medication half has a trial behind it. In two urban emergency departments, 411 adults with significant acute pain in an arm or leg were randomized. One group got 400 mg of ibuprofen with 1,000 mg of acetaminophen. The others got an opioid combination, three kinds in all. At two hours, the drop in pain did not differ in any statistical or clinical sense. That was one dose, and side effects were not measured, so it is a starting point, not a promise.

Is opioid stewardship the same as refusing opioids?

No. Stewardship is harm reduction sized to one person. A blanket rule fails in both directions. Withhold from everyone and you leave real pain untreated, which keeps people from sleeping, moving and working. Hand out to everyone and you seed long-term use in people who never needed it.

My path was personal. Yours may need to look different. Some patients need opioids. Turning the prescription down sometimes works, and it is the option we tend to ignore. Every person is built differently, so we take each patient as they come through the door, not as a chart predicted they would be.

For patients already taking opioids, interventional procedures carry part of the load so the dose can come down, and withdrawal is kept off the table as it does. Our opioid stewardship page explains how that works.

What does this mean for your next injury?

If a first prescription is on the table, the studies above point to where your leverage is: the number of days, whether a second prescription follows, and your own risk profile. Tell the prescriber about smoking, past alcohol or drug problems, depression or anxiety, and pain you had before this injury, because those are what predicted persistent use. Then decide together. If you want help building that plan, here is what to bring to a first visit.

Common questions