SAFE GC Coalition: Emergency Department Opioid Prescriptions

The opioid epidemic has clearly demonstrated that a generation of patients seeking emergency care was exposed to potential harm from opioid prescriptions. Emergency departments (EDs) were always—and remain—a relatively small source of opioids. Regardless, patients uneducated to the addictive properties of opioids may develop high-risk or persistent use even with a single prescription after an ED visit. Curtailing ED prescriptions became a target for clinicians and policy makers seeking to mitigate the opioid epidemic.

A recent research article reviewing ED prescribing activity published in JAMA Network Open found that interventions to reduce ED opioid prescribing have generally succeeded. Most studies included in their review demonstrated reductions in the number of patients who received opioid prescriptions. Further analysis revealed interventions were associated with a statistically significant and clinically meaningful decrease in the rate of opioid prescriptions.

During the decade in which these studies were performed, the baseline rate of ED opioid prescribing has fallen across the US. The Centers for Disease Control and Prevention found that 14.6% of ED visits resulted in an opioid prescription in 2016 compared with a peak of 21.5% in 2010; this rate is likely to be even lower with more recent data. Opioids are most often prescribed to patients with acute pain due to common illnesses, including dental pain, and fractures. Clinicians have also altered their choice of analgesics, with an increase in the proportion of prescriptions for opioids perceived to be less potent (eg tramadol hydrochloride).

Researchers sought to determine whether any patients discharged from the ED needed an opioid prescription. If the answer is not zero, then what is the right number, and for which conditions? An expanding body of evidence suggests that opioids are no more effective in addressing pain than other analgesics, such as nonsteroidal anti-inflammatory drugs, for common self-limited conditions typically treated in the ED. The list of conditions for which short courses of opioids are appropriate has dwindled. There are likely small populations of patients in the ED who still require short-term opioids, such as patients with severe pain or contraindications to alternative therapies. Researchers found evidence of effective strategies to reduce ED opioid prescribing and accelerated the declining national trend. The new challenge is to optimize and tailor prescriptions for patients and scenarios in which opioids are indicated—that is, determining the right quantity for the right patients. The path forward must incorporate patient-centered approaches rather than to exclusively target prescriber behavior. A striking finding is that none of the 63 studies reviewed reported the level of pain or ability to manage pain for patients. Clinicians may fear that focusing on patient satisfaction invariably leads to more opioid prescriptions; however, responsible strategies that incorporate shared decision-making for select patients and conditions may avoid past mistakes. This finding reinforces the need for more evidence to determine the right quantity of medication prescribed.

Significant progress has been made during the past decade to reduce opioid prescriptions for patients discharged from the ED. Ensuring that opioids are prescribed appropriately should continue to be a priority for every ED. However, the goal for the next 10 years must shift. Clinicians, health systems, and policy makers should seek to optimize opioid prescribing and incorporate patient perspectives. Furthermore, all EDs should be able to prescribe buprenorphine hydrochloride, an effective treatment for opioid use disorder, and provide naloxone hydrochloride for overdose prevention. Preventing unnecessary exposure to opioids is critical however researchers maintain that any hope to end the opioid epidemic demands increased access to effective treatment for opioid use disorder.

JAMA Network Open is a monthly open access medical journal published by the American Medical Association covering all aspects of the biomedical sciences. For more information please visit www.jamanetwork.com

The SAFE Glen Cove Coalition is conducting an opioid prevention awareness campaign entitled. “Keeping Glen Cove SAFE,” in order to educate and update the community regarding opioid use and its consequences. To learn more about the SAFE Glen Cove Coalition please follow us on www.facebook.com/safeglencovecoalition or visit SAFE’s website to learn more about the Opioid Epidemic at www.safeglencove.org.