“Considering the evidence and specialty guidelines from the American College of Physicians, American Pain Society, and American College of Emergency Physicians that support conservative management rather than opioids as initial therapy for AOLBP, we still have a ways to go, but it’s a start,” Dr del Portal said.

Directions for Future Research

According to Dr del Portal, future efforts should explore ways for healthcare providers to support recovery from opioid addiction; limiting overprescribing is an important first step. Prescribing guidelines appear to be an effective part of the solution, and additional research is needed to explore the safety and efficacy of opioid alternatives.

TRENDING ON CPA: More than 75% of High School Heroin Users Started With Prescription Opioids 

Dr. Deitz, an internal medicine specialist with nearly 20 years of ED experience, is interested in determining whether institutional quality is an indicator of best prescribing practices.

“If a patient is seen in a facility that scores high according to indicators of high-quality health care, is that patient less likely to receive opioids or other inappropriate care than a patient seen at a facility that appears to be a lower performer?,” Dr Deitz asked.

Though opioids are generally not an appropriate first-line treatment for back pain, they may be indicated under certain circumstances. One benefit of a voluntary rather than mandatory guideline is that it allows room for clinical discretion.

“The guideline still offers prescribers the discretion to decide on the best therapy for an individual patient, but it promotes a conversation with patients about the risks of opioids, and facilitates the discussion when a prescriber decides an opioid is not in the patient’s best interest,” Dr del Portal concluded.

References

1. Lee SS, Choi YS, Pransky GS. Extent and Impact of Opioid Prescribing for Acute Occupational Low Back Pain in the Emergency Department. J Emerg Med. 2016 Jan 2. pii: S0736-4679(15)01150-6. doi: 10.1016/j.jemermed.2015.10.015.

2. Del Portal DA, Healy ME, Satz WA, McNamara RM. Impact of an Opioid Prescribing Guideline in the Acute Care Setting. J Emerg Med. 2016 Jan;50(1):21-7. doi: 10.1016/j.jemermed.2015.06.014. Epub 2015 Aug 15. 

3. Webster BS, Verma SK, Gatchel RJ. Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery and late opioid use. Spine (Phila Pa 1976). 2007 Sep 1;32(19):2127-32.

4. Franklin GM, Stover BD, Turner JA, Fulton-Kehoe D, Wickizer TM. Early opioid prescription and subsequent disability among workers with back injuries: the Disability Risk Identification Study Cohort. Spine (Phila Pa 1976). 2008 Jan 15;33(2):199-204. doi: 10.1097/BRS.0b013e318160455c.

5. Poon SJ, Greenwood-Ericksen MB. The Opioid Prescription Epidemic and the Role of Emergency Medicine. Ann Emerg Med. 2014 Nov;64(5):490-5. doi: 10.1016/j.annemergmed.2014.06.016. Epub 2014 Jul 11. 

6. California Workers’ Compensation Institute. Changes in Schedule II & Schedule III opioid prescriptions and payments in California workers’ compensation. 2012.