Pain management and sedation/original research
Association of Emergency Department Opioid Initiation With Recurrent Opioid Use

https://doi.org/10.1016/j.annemergmed.2014.11.015Get rights and content

Study objective

Acute pain complaints are commonly treated in the emergency department (ED). Short courses of opioids are presumed to be safe for acute pain; however, the risk of recurrent opioid use after receipt of an ED opioid prescription is unknown. We describe the risk of recurrent opioid use in patients receiving an opioid prescription from the ED for an acute painful condition.

Methods

This is a retrospective cohort study of all patients discharged from an urban academic ED with an acute painful condition during a 5-month period. Clinical information was linked to data from Colorado’s prescription drug monitoring program. We compared opioid-naive patients (no opioid prescription during the year before the visit) who filled an opioid prescription or received a prescription but did not fill it to those who did not receive a prescription. The primary outcome was the rate of recurrent opioid use, defined as filling an opioid prescription within 60 days before or after the first anniversary of the ED visit.

Results

Four thousand eight hundred one patients were treated for an acute painful condition; of these, 52% were opioid naive and 48% received an opioid prescription. Among all opioid-naive patients, 775 (31%) received and filled an opioid prescription, and 299 (12%) went on to recurrent use. For opioid-naive patients who filled a prescription compared with those who did not receive a prescription, the adjusted odds ratio for recurrent use was 1.8 (95% confidence interval 1.3 to 2.3). For opioid-naive patients who received a prescription but did not fill it compared with those who did not receive a prescription, the adjusted odds ratio for recurrent use was 0.8 (95% confidence interval 0.5 to 1.3).

Conclusion

Opioid-naive ED patients prescribed opioids for acute pain are at increased risk for additional opioid use at 1 year.

Introduction

Unintentional opioid overdoses have surpassed motor vehicle crashes as the leading cause of injury death in the United States. The majority of these deaths are from prescription opioids. Moreover, as the number of opioid prescriptions has increased, chronic opioid use and opioid dependence have become major public health issues in the United States.1, 2, 3, 4 Because opioids are frequently prescribed to patients discharged from the ED, it is important to understand the relationship between ED opioid prescribing and risk of progressing to recurrent opioid use. Ultimately, the ED may be an important site of intervention.1, 5

Editor’s Capsule Summary

What is already known on this topic

Opioid analgesics can create dependence and addiction.

What question this study addressed

Does emergency department (ED) opioid prescribing for acute pain increase the risk of future prescription opioid use in the next year?

What this study adds to our knowledge

In this review of more than 4,800 patients, 48% received an opioid prescription. Opioid-naive study patients who filled an opioid analgesic prescription were nearly twice as likely to receive a later opioid prescription compared with those who did not receive a prescription.

How this is relevant to clinical practice

Although shedding light on the pattern of opioid use after an ED visit for acute pain, these results highlight the need for better understanding of the role of this treatment in misuse or harm.

The risk of recurrent opioid use after a single prescription has been assumed to be minimal6, 7; however, a recent study reported that patients discharged from ambulatory surgery with a first-time opioid prescription are 44% more likely to fill additional opioid prescriptions 1 year after discharge compared with opioid-naive patients who did not receive an opioid prescription.8 This raises the important question of whether ED opioid initiation for acute pain increases the risk of recurrent opioid use. To our knowledge, there have been no studies to date describing the risk of recurrent opioid use in a population of ED patients treated for acute pain. The objective of this study was to describe the risk of recurrent opioid use among ED patients initiating treatment with opioids.

Section snippets

Study Design and Setting

This was a retrospective cohort study of all adult patients with an acutely painful diagnosis (see inclusion diagnoses below) who were discharged from the ED within a 5-month interval. The University of Colorado Hospital is an urban, academic ED with approximately 80,000 visits annually and an admission rate of 20%. All ED prescriptions are ordered electronically by an electronic medical record system: Epic 2010 (Epic Systems, Verona, WI).

Permission to access Colorado’s prescription drug

Results

During the study period, there were 5,597 patients with an acute pain complaint discharged from the ED. Of these patients, 715 had repeated visits, 75 met the exclusion criteria, and 6 had incomplete data (Figure). The patients with missing data were identified after the data set had been encrypted to protect patient confidentiality and therefore were not reinvestigated. The remaining 4,801 patients were included in the cohort described in Table 1. There were 2,243 patients (47%) who received

Limitations

The retrospective, observational design of our study does not assess causation. The greatest threat to the internal validity of our findings is selection bias. In an ideal study, there would be no baseline differences in the characteristics of patients who were prescribed opioids and those who were not. Additionally, it is possible that some patients had more severe presentations of the selected acute painful conditions at ED presentation and this severity was associated with recurrent use. In

Discussion

Prescribing opioids from the ED is an accepted part of the treatment of acute pain, and the rate of ED opioid prescribing is increasing.11 Unfortunately ED prescribing may also be a gateway to recurrent opioid use. In this study, 17% of patients who filled their first opioid prescription for a minor painful condition were still receiving opioids 1 year after the index ED visit. Eight percent to 10% of opioid-naive patients who did not use opioids after discharge (either did not receive a

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Please see page 494 for the Editor’s Capsule Summary of this article.

Supervising editor: Lewis S. Nelson, MD

Author contributions: All authors were responsible for conceiving the study, data collection and analysis, conclusions, and writing the article. JAH takes responsibility for the paper as a whole.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist and provided the following details: Professional research assistant support for the project was provided by a pilot grant from the University of Colorado Department of Emergency Medicine. The use of Research Electronic Data Capture in this project was supported by National Institutes of Health (NIH)/National Center for Research Resources (NCRR) Colorado CTSI grant UL1 RR025780.

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