Emergency department opioid prescribing
The Emergency Department (ED) is at the convergence of the opioid epidemic as emergency physicians (EPs) routinely care for patients with adverse effects from opioids, including overdoses and those battling addiction, as well as treating patients that benefit from opioid use. Increasingly, EPs are required to distinguish between patients who are suffering from a condition that warrants opioids to relieve pain, and those who may be attempting to obtain these medications for other purposes, such as abuse or diversion. Overall, opioid pain reliever prescribing in the ED setting has increased over the past decade, but until now, the question of how ED prescribing is contributing to opioid use had not been clearly defined.
In new research published online by the Annals of Emergency Medicine, researchers from Brigham and Women's Hospital (BWH) found that the majority of opioid prescriptions in the ED setting had a low pill count and almost exclusively were immediate-release formulations, not the long-acting medications such as methadone, Oxycontin and MS-Contin, which are more strongly associated with overdoes.
"Our data show that opioid prescribing in the ED is done with caution and aligned with short-term use goals. The median number of pills per prescription was 15, and only 1.5 percent of prescriptions were for more than 30 pills, suggesting that emergency physicians (EPs) generally follow guideline recommendations to limit opiod prescriptions to only 3-5 days, and avoid long-acting opiods," said Scott G. Weiner, MD, MPH, corresponding author of the study and emergency physician at BWH.
To accurately describe opioid prescribing in the ED, researchers used a national sample of ED patients treated during a single week in October 2012 to analyze the characteristics of patients and opioid prescriptions. Researchers examined the indications for opioid pain reliever prescribing, characteristics of opioids prescribed both in the ED and at discharge, and characteristics of patients who received opioid pain relievers compared with those who did not.
The national sample was representative of 19 EDs representing 1.4 million annual visits, varied geographically, and were from predominantly academic medical centers. The prerequisite for inclusion in the study was presence of an electronic medical record that allowed the hospitals to accurately determine if a patient was discharged from the ED with an opioid prescription. During the study week, 27,516 patient visits were evaluated; 19,321 patients (70.2 percent) were discharged and 3,284 (11.9 percent of all patients and 17 percent of discharged patients) received an opioid pain reliever prescription. For patients prescribed an opioid pain reliever, the mean age was 41 years and slightly more than half were women.
When looking at the diagnoses that were associated with prescribing, researchers found that musculoskeletal back pain and abdominal pain were the most common reasons that patients received an opioid prescription (about 10 percent each), followed by extremity fracture (7 percent), extremity sprain (6.5 percent) and dental/oral issues (6.2 percent). The most common opioid pain relievers prescribed were oxycodone and hydrocodone.
"We hope that this study will add to the literature and inform policy-makers about the actual scope of ED opioid prescribing, so that efforts to address addiction and reduce inappropriate prescribing can be accurately focused," Weiner said.