Elsevier

Annals of Emergency Medicine

Volume 66, Issue 3, September 2015, Pages 253-259.e1
Annals of Emergency Medicine

Pain management and sedation/original research
Opioid Prescribing in a Cross Section of US Emergency Departments

Presented at the American College for Medical Toxicology Annual Scientific Meeting, March 2015, Clearwater Beach, FL.
https://doi.org/10.1016/j.annemergmed.2015.03.026Get rights and content

Study objective

Opioid pain reliever prescribing at emergency department (ED) discharge has increased in the past decade but specific prescription details are lacking. Previous ED opioid pain reliever prescribing estimates relied on national survey extrapolation or prescription databases. The main goal of this study is to use a research consortium to analyze the characteristics of patients and opioid prescriptions, using a national sample of ED patients. We also aim to examine 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.

Methods

This observational, multicenter, retrospective, cohort study assessed opioid pain reliever prescribing to consecutive patients presenting to the consortium EDs during 1 week in October 2012. The consortium study sites consisted of 19 EDs representing 1.4 million annual visits, varied geographically, and were predominantly academic centers. Medical records of all patients aged 18 to 90 years and discharged with an opioid pain reliever (excluding tramadol) were individually abstracted by standardized chart review by investigators for detailed analysis. Descriptive statistics were generated.

Results

During the study week, 27,516 patient visits were evaluated in the consortium EDs; 19,321 patients (70.2%) were discharged and 3,284 (11.9% of all patients and 17.0% of discharged patients) received an opioid pain reliever prescription. For patients prescribed an opioid pain reliever, mean age was 41 years (SD 14 years) and 1,694 (51.6%) were women. Mean initial pain score was 7.7 (SD 2.4). The most common diagnoses associated with opioid pain reliever prescribing were back pain (10.2%), abdominal pain (10.1%), and extremity fracture (7.1%) or sprain (6.5%). The most common opioid pain relievers prescribed were oxycodone (52.3%), hydrocodone (40.9%), and codeine (4.8%). Greater than 99% of pain relievers were immediate release and 90.0% were combination preparations, and the mean and median number of pills was 16.6 (SD 7.6) and 15 (interquartile range 12 to 20), respectively.

Conclusion

In a study of ED patients treated during a single week across the country, 17% of discharged patients were prescribed opioid pain relievers. The majority of the prescriptions had small pill counts and almost exclusively immediate-release formulations.

Introduction

Pain is the most common reason for an emergency department (ED) visit; almost two thirds of patients seeking ED care do so for acute pain or acute exacerbations of chronic pain.1, 2 Emergency physicians frequently treat pain with opioid pain relievers.3 Unfortunately, opioid misuse, addiction, overdose, and diversion have reached epidemic proportions in the United States.4 The contribution of ED prescribing to problematic opioid use is not clearly defined. Also, the rate of ED opioid prescribing and the attributes of ED opioid prescriptions have not been directly studied on a large scale, to our knowledge.

Editor’s Capsule Summary

What is already known on this topic

Prescriptive opioid use and harm increased during the past decades, prompting some to seek emergency department (ED) opioid prescribing limits.

What question this study addressed

What is the pattern of ED opioid deployment after discharge?

What this study adds to our knowledge

In a 1-week cross-sectional survey of 19 EDs across the United States, chart review revealed an opioid prescription frequency at discharge of 11.9% for all patients and 17.0% for discharged patients. The quantities were small (mean ≈15 tablets) and overwhelmingly for oral short-acting agents.

How this is relevant to clinical practice

ED opioid prescribing reduction efforts will likely have modest effect because opioids currently appear to be deployed with caution and aligned with short-term use goals.

Future research we would like to see

A longitudinal study of how ED opioid prescribing affects patients or creates future harm.

Opioid pain relievers are an accepted treatment for outpatient management for patients with moderate to severe acute pain.5 ED providers care for patients with a spectrum of pain severity and causes, and nationally emergency physicians are among the most frequent prescribers of opioid pain relievers in patients younger than 40 years.6 A recent study found that approximately one third of all ED patients receive an opioid either administered in the ED or prescribed at discharge, up from 21% in a span of 10 years.7 Prescribing behavior is complicated by the nature of emergency care, which is often provided without the benefit of an established patient-physician relationship and in an environment characterized by limited time and resources.

This study sought to describe the characteristics of opioid pain reliever prescriptions from a cluster of consecutive visits in a 1-week period across a large national sample of ED patients. Additionally, we sought to examine the indications for opioid pain reliever prescribing, doses provided both in the ED and prescribed at discharge, and characteristics of patients who received opioid pain relievers compared with other patients evaluated in the ED during this period.

Section snippets

Study Design and Setting

This was a retrospective cohort study of consecutive ED visits in a 1-week period during October 2012. The 19 EDs participating in the study consortium were geographically distributed throughout the United States and were primarily academic (16/19) (Appendix E1, available online at http://www.annemergmed.com). Annual ED census ranged from 42,000 to 230,000 (median 80,000) and in total represented approximately 1.4 million visits per year. In accordance with a small sample of hospital data, we

Results

Overall, there were 27,516 total patient visits at the 19 participating hospital sites during the study week. 19,321 patients (70.2%) were discharged, and 3,284 patients (11.9% of all patients and 17.0% of discharged patients) received an opioid pain reliever prescription for the purpose of treating pain. Detailed characteristics of the 3,284 patients discharged with an opioid prescription compared with discharged patients who did not receive an opioid prescription are displayed in Table 1. The

Limitations

Our data provide a snapshot of prescribing across several academic institutions during a 1-week sample and may not reflect prescribing throughout the spectrum of hospitals, settings, and periods. To address these threats to external validity, we included geographically diverse centers. A majority of the sites (16/19) were academic, limiting the application of our findings to nonacademic sites. We used 7 consecutive days of data and specifically chose a week with no holidays to avoid any

Discussion

Opioid abuse and overdose have reached epidemic proportions in the United States, and recent attention has been focused on ED opioid pain reliever prescribing guidelines and prescription drug monitoring programs to potentially decrease diversion and reduce overdose rates.5, 9, 10, 11, 12 Despite these interventions, little is known about actual prescribing behaviors of emergency providers. Our results using individual record abstraction reinforce the findings of previous studies that relied on

References (23)

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Please see page 254 for the Editor’s Capsule Summary of this article.

Supervising editor: Donald M. Yealy, MD

Author contributions: JAH, LSN, JP, and SGW were responsible for study concept and design. All authors were responsible for acquisition of the data and critical revision of the article for important intellectual content. SGW was responsible for analysis and interpretation of the data and statistical expertise. JAH, LSN, JP, and SGW drafted the article. BWM and ACP obtained funding (only for work at the Emory/Grady site). JAH, LSN, JP, and SGW were responsible for study supervision. SGW takes responsibility for the paper as a whole.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist and provided the following details: Authors from Emory/Grady were supported in part by a Faculty Pilot Grant Program from the Emory Center for Injury Control, Emory University, Centers for Disease Control and Prevention grant 5R49CE001494. Authors from the University of Colorado, Denver declare that professional research assistant support for the project was provided by a pilot grant from the University of Colorado Department of Emergency Medicine. The use of REDCap in this project was supported by National Institutes of Health (NIH)/National Center for Research Resources Colorado Clinical and Translational Science Institute grant UL1 RR025780.

The contents of this study are the authors’ sole responsibility and do not necessarily represent official NIH views.

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All members are listed in the Appendix.

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