To call opioid use in the US a “problem” is a gross understatement, and most of us in Emergency Medicine appreciate this. You may believe that if you only prescribe a small number of pills to an opioid-naïve patient who is truly in pain, you are not causing harm. A new study in the New England Journal of Medicine suggests we may be doing more damage than we realize.
Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use, a new study by Barnett et al., appeared in the NEJM on February 16, 2017. This retrospective analysis of Medicare beneficiaries looked at patients who were seen in the ED between 2008 and 2011 and left with an opioid prescription. None of the patients had received an opioid prescription in the previous six months. ED physicians were categorized as low-intensity or high-intensity opioid prescribers based on the percentage of their patients who left the ED with an opioid prescription. The primary outcome was long-term opioid use (> 180 days).
In all, 215,678 patients were treated by a low-intensity prescriber, and 161,951 were treated by a high-intensity prescriber. Astoundingly, the average rate of opioid prescription (by percentage of visits) was 24.1% for high-intensity prescribers. The average was 7.3% for low-intensity prescribers. Long-term opioid use at 12 months was significantly higher among patients treated by high-intensity prescribers, and for every 48 patients prescribed an opioid, the authors estimated that approximately one became a long-term user. Moreover, visits to the ED for opioid-related problems and for falls and fractures were significantly higher in patients treated by a high-intensity prescriber.
Is it all our fault?
No, it isn’t. We may be the ones writing the initial prescription, but if a patient is still using opioids after 180 days, he or she has probably obtained more from a primary care doctor. The study authors suggest an “inertia,” hypothesizing that if the ED physician prescribed an opioid and it worked well, it’s easy to continue prescribing it.
Still, we are the ones setting our patients (and in this study, our elderly patients in particular), on this path. In a New York Times article discussing this study, Dr. Lewis Nelson (not a study author) states that “It puts the burden on us in the E.R. to be even more thoughtful about how to do things.” Wise words with which to go forward.
- Barnett ML, Olenski AR, Jena AB. Opioid-prescribing patterns of emergency physicians and risk of long-term use. N Engl J Med. 2017;376(7):663-73.
- Hoffman J. Long-term opioid use could depend on the doctor who first prescribed it. New York Times. 15 February 2017.