A Complicated Clinical Question: Radiology’s Role in the Opioid Crisis

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.