Author: Molly M. Jeffery, PhD @mollyjeffery
Everyone “knows” they hand out opioids like candy in the ED. Or if they don’t now, they certainly used to.
That idea didn’t square with the clinical experience of any of the ED doctors I’ve talked to. We wanted to know what the clinical reality is across the country, so we used the OptumLabs Data Warehouse to look at opioid prescribing for acute pain in the ED and other settings. OLDW has a huge dataset of insurance claims covering millions of people over 20+ years. We looked at data from 2009-2015, focusing on people who were opioid naïve (no opioid fills in the past 6 months) and who did not have cancer and were not in hospice. We converted all the prescriptions into mg of morphine equivalents (MME) to have a common unit of measure across drugs.
We compared the ED to other settings on how often prescriptions aligned with best practices for acute opioid prescribing on days supplied, daily dose, and opioid formulation (long-acting vs. immediate release). Then we followed people to find out whether they continued to use opioids after that initial prescription. (We used the CONSORT definition of chronic opioid use: an episode lasting 90+ calendar days and including either 10 fills or 120+ days supply.)
The CDC recommends [https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf] acute prescriptions should be for less than 7 days supply, but less than 3 days is better. There is little guidance on the best starting dose, but the CDC recommends that chronic opioid users (who have built up some tolerance) remain below 90 MME, but below 50 MME is safer. Finally, the CDC says opioid treatment should start with immediate release opioids; extended release/long-acting formulations are generally dangerous for opioid naïve people.
In brief, the results of our study was that prescriptions written in the ED were more likely to meet each of the measures of safe prescribing than prescriptions written in other settings: they were shorter and for lower doses, and they were more likely to be immediate-release. And patients receiving their prescription in the ED were less likely to continue to use opioids.
These weren’t small differences. You can check out the paper for full results, but as an example, among the commercially insured, 3.1% of prescriptions written in the ED exceeded 7 days vs. 19.1% written in non-ED settings; 14.3% of prescriptions written in the ED exceeded 50 MME per day vs. 22.8% of prescriptions written in non-ED settings. (With a sample size of >5.2 million prescriptions, all of these differences are statistically significant at any conventional level.)
And patients receiving prescriptions written in the ED were 46% to 58% less likely to continue using opioids chronically than those seen in non-ED settings.
ED physicians will probably not be surprised by our findings, but they may be surprising to other physicians and policymakers. We checked whether this pattern has changed over time. It hasn’t; the ED was better than non-ED settings across the whole study period.
I would guess that some non-ED physicians will argue that the patients seen in the ED are so different that this isn’t a fair comparison. It’s true that patients don’t randomly decide whether to show up at the ED or another setting (like primary care or surgeons office) for treatment of their pain. We address some of this difference by limiting our population to people who are not currently taking prescription opioids and excluded cancer and hospice patients—in nearly all these cases, the recommended opioid treatment regimen is the same: a short course of opioids at a low dose.
Furthermore, we found that in all treatment settings, patients receiving prescriptions that met all our measures were less likely to continue to use opioids. The differences were huge in the non-ED setting: the risk of continued use was about 4 times higher with prescriptions that didn’t meet the measures vs. those written in the same setting that did meet the measures.
We hope that this research will be helpful to physicians and patients deciding how to treat acute pain. The characteristics of your first opioid prescription are strongly associated with your risk of continuing to use opioids long term. Given the suffering caused by opioid misuse and addiction, I think many people may be willing to try non-opioid treatments for their pain to reduce their risk of long term opioid use. Although a small number of people may eventually need opioids, avoiding opioids as a first line of treatment for acute pain makes a lot of sense.