Relative to education and guidelines alone, restricted access to oxycodone effectively reduced administration of oxycodone in the emergency department (ED), according to study results published in the British Journal of Pain.
Educational programs and prescribing guidelines aimed at reducing opioid use in the ED have had modest effects, with a substantial proportion of ED patients still being prescribed oxycodone.More extreme measures, such as restricting the supply of a medication, have demonstrated stronger, immediate, and persistent effects; however, this approach should only be used when evidence of harm from the medication outweighs its potential benefits to the patient. Study authors sought to assess the effectiveness of a restrictive intervention to limit oxycodone access in the ED.
The authors allocated patients over 18 to 75 years of age presenting to the ED to 7 days in the intervention arm (restricted oxycodone, or ROXY) or 7 days in the standard of care arm. Eligible patients included those who received analgesia in the ED; the authors identified these patients retrospectively using medication dispensing logs. In the week during which ED patients were randomized to ROXY, the clinical pharmacist removed all immediate release (IR) 5 mg oxycodone tablets from the ED medication stock, leaving only a small supply in the Trauma Center that could be used only with approval from the clinical pharmacist or selected senior nurses.
In the week during which patients were randomized to standard of care, nursing staff had access to IR 5 mg oxycodone and standard clinical practices were carried out.
The primary study outcome was the proportion of patients administered oxycodone in the ED among patients who received an analgesic in the ROXY vs standard of care arms, as determined by an unadjusted chi-square test. Secondary outcomes included administration rates of other analgesic medications, the proportion of patients discharged home with oxycodone prescriptions and the time to first analgesic.
A total of 3014 patients randomly assigned, 1309 were allocated to ROXY, (mean age, 43.4 years; 54.1% men; 65.4% self-presenting to the ED) and 949 (mean age, 42.8 years; 52.7% men; 63.1% self-presenting to the ED) were allocated to standard care. The 2 groups were similar in terms of baseline characteristics, presenting complaint, and pain score. Oxycodone was administered to 80 (6.1%) patients in the ROXY group and 221 (23.3%) in the standard of care group (absolute risk difference, −0.17 [95% CI, −0.20 to −0.14]).
The authors noted no significant difference between the 2 groups in time to first analgesic.On discharge, significantly fewer patients were prescribed oxycodone in the ROXY group vs the standard of care group (relative risk, 0.51; 95% CI, 0.39-0.66). The restricted access to oxycodone was associated with a significant reduction of oxycodone administration in the ED.
Limitations of the study include its study design; the exclusion certain patients, setting in a major trauma center, and the inability to completely restrict access to oxycodone.
“Restricted access to oxycodone was superior to education and guideline modifications alone for reducing oxycodone use in the ED and reducing discharge prescriptions of oxycodone from the ED,” the authors concluded. They added, “The addition of simple restrictive interventions is recommended to enable rapid changes to clinician behaviour to reduce the potential harm associated with the prescribing of oxycodone in the ED.”
Mitra B, Roma C, Wu B, et al. Restriction of oxycodone in the emergency department (ROXY-ED): a randomized controlled trial. Brit J Pain. Published online July 12, 2023. doi:10.1177/20494637231189031