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January 28, 2020

Substantial Decline in Opioid Prescribing at Emergency Department Visits

Author Affiliations
  • 1Consulting Editor, JAMA Health Forum and JAMA
JAMA Health Forum. 2020;1(1):e200026. doi:10.1001/jamahealthforum.2020.0026

The rate of opioid prescribing for adults visiting US emergency departments (EDs) decreased markedly from 2006 through 2017, representing a decline of about 30%, according to a report released this month from the US Centers for Disease Control and Prevention’s National Center for Health Statistics. The report is based on nationally representative data from the 2006-2017 National Hospital Ambulatory Medical Care Survey.

“Exposure to an opioid prescription in the ED has been identified as a potential risk factor for long-term use, with one study reporting that 17% of patients who filled their first opioid prescription for a minor painful condition were still receiving opioids 1 year later,” the report notes. Prescribed opioids were associated with more than one-third of the 47 000 opioid-associated overdose deaths in 2017.

The percentage of ED visits by adults that resulted in opioids prescribed at discharge increased from 19.0% in 2006-2007 to 21.5% through 2010-2011 but then decreased to 14.6% in 2016-2017—translating to an overall reduction of 30.1% during the study period. Although these trends applied to adults younger than 65 years, with the highest rate of decrease among visits by younger adults (ages 18-44 years), the percentage of visits with an opioid prescribed at discharge remained stable for adults 65 years and older.

Opioid prescription rates at discharge decreased overall for drugs stronger than morphine (acetaminophen-oxycodone and oxycodone) and increased for drugs weaker than morphine (tramadol and acetaminophen-codeine). In 2014, prescriptions for acetaminophen-hydrocodone began to decline after increasing levels of abuse of this drug prompted its reclassification from a schedule III to a schedule II controlled substance. Even so, acetaminophen-hydrocodone remained the most frequently prescribed opioid at the end of the period covered by the survey (2016-2017), making up 41.5% of prescriptions at ED discharge. Tramadol was the second most frequently prescribed drug at discharge (21.1% of prescriptions, an increase from 6.7% a decade earlier).

The most common reasons for which patients in an ED received an opioid prescription in 2016-2017 included dental pain, stones in the kidneys or urinary tract, fractures, and back pain. The largest declines in opioid prescriptions occurred among patients with headache or migraine, extremity pain, and back pain.

Growing evidence indicates that opioids should not be the first-line treatment for headache and migraine in the ED. The report also notes that the decrease in prescribing might be a response by clinicians to the opioid epidemic, combined with evidence that nonopioid painkillers are as effective as commonly prescribed opioids in treating acute extremity pain and low back pain.

The report notes the importance of continuing to assess trends in ED opioid prescribing “to monitor the effects of public health policy at the national level.” The report, Trends in Opioids Prescribed at Discharge From Emergency Departments Among Adults: United States, 2006-2017, is available at https://www.cdc.gov/nchs/data/nhsr/nhsr135-508.pdf.

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