ED Physicians’ Role In Opioid Misuse

In an article recently published in Pain Practice, researchers at the University of Connecticut and Johns Hopkins University reviewed studies that examined the role of emergency department (ED) doctors in the US opioid epidemic.¹     

With the rapid increase in opioid prescriptions in recent decades, rates of misuse, diversion, overdose, and associated mortality have risen sharply. In 2013, opioids were the cause of one-third of overdose-related deaths in US adults age 25 to 64, surpassing motor vehicle accidents as the most common cause of injury-related death in this age group.²

Although ED physicians were once thought to under-treat pain — a phenomenon known as oligoanalgesia — they were recently found to be the third most common prescribers of opioid analgesics to young adults.^3,4 Despite the significant contribution of such behavior to the opioid epidemic, the precise role of ED physicians had not yet been elucidated.

 

“Gaining a more in-depth understanding of the role that the ED plays in [opioid pain relievers] OPR misuse and diversion could help inform the development of more focused ED-centered prevention interventions,” wrote the investigators. To that end, they reviewed research pertaining to opioid prescriptions obtained from the ED. They identified 7 studies, the main findings of which are summarized below.

• A prospective observational study showed that 42% of patients who received an opioid prescription in an ED misused the medication, most commonly by taking more OPRs than prescribed.
• A study that examined medical claims from a 1-year period found inappropriate prescribing practices — such as a high daily dose or overlapping prescriptions — in 10.3% of ED patients who received an opioid prescription, especially women.
• In a study on prescription drug diversion, the ED was cited as the main source of opioid prescriptions in 10% of patients who diverted medication.
• A retrospective observational study determined that urgent care/ED doctors wrote the least number of controlled prescriptions compared with several other specialties such as primary care and psychiatry; only 6.6% of opioid prescriptions examined in the study originated from urgent care/ED physicians.
• Other findings showed that 5.7% of opioid-related deaths in Utah between 2002 and 2010 were associated with prescriptions from ED physicians vs 39% from family medicine/internal medicine physicians.
• In a qualitative study, some prescription drug abusers identified hospital emergency rooms as sites for doctor shopping, and a qualitative study of prescription drug dealers reported that 1 had stolen prescription pads from the ED.

“Although the ED appears to play a lesser role than dealers or pain management clinics as the source of misused OPRs, the ED is uniquely a location that can implement interventions to reduce the burden of OPR misuse,” such as patient education about opioid-related risks, the investigators concluded. “State and hospital-based OPR prescribing guidelines may help ED physicians make pain management decisions and may support them in explaining their decisions to patients.”

Summary and Clinical Applicability

Approximately 10% of opioid prescriptions ordered by ED physicians may be inappropriately prescribed, and up to 42% of these medications may be misused. 

Limitations

The researchers only used 2 search engines, which could have resulted in overlooking relevant studies. In addition, the scarcity of quantitative studies on the topic and the lack of specificity in many studies regarding the type of medical setting, prevent definitive conclusions.

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References

1. Lyapustina T, Castillo R, Omaki E, et al. The contribution of the emergency department to opioid pain reliever misuse and diversion: a critical review. Pain Pract. 2017; doi:10.1111/papr.12568
2. Centers for Disease Control and Prevention. Prescription drug overdose in the United States: Fact Sheet. www.mayorsinnovation.org/images/uploads/pdf/1_-_Prescription_Drug_Overdose_in_the_United_States.pdf. Accessed March 30, 2017.
3. Rupp T, Delaney KA. Inadequate analgesia in emergency medicine. Ann Emerg Med. 2004: 43;494-503.
4. Volkow ND, McLellan TA, Cotto JH. Characteristics of opioid prescriptions in 2009. JAMA. 2011; 305(13):1299-1301.e of medical setting, prevent definitive conclusions.