Temporal Factors Associated With Opioid Prescriptions for Patients With Pain Conditions in an Urban Emergency Department | Clinical Pharmacy and Pharmacology | JAMA Network Open | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 35.173.234.169. Please contact the publisher to request reinstatement.
1.
Guy  GP  Jr, Zhang  K, Bohm  MK,  et al.  Vital signs: changes in opioid prescribing in the United States, 2006-2015.  MMWR Morb Mortal Wkly Rep. 2017;66(26):697-704. doi:10.15585/mmwr.mm6626a4PubMedGoogle ScholarCrossref
2.
Centers for Disease Control and Prevention.  2018 Annual Surveillance Report of Drug-Related Risks and Outcomes—United States: Surveillance Special Report. Centers for Disease Control and Prevention; 2018.
3.
Davenport  S, Weaver  A, Caverly  M. Economic impact of non-medical opioid use in the United States. Society of Actuaries. Published October 2019. Accessed January 10, 2020. https://www.soa.org/globalassets/assets/files/resources/research-report/2019/econ-impact-non-medical-opioid-use.pdf
4.
Axeen  S, Seabury  SA, Menchine  M.  Emergency department contribution to the prescription opioid epidemic.  Ann Emerg Med. 2018;71(6):659-667.e3. doi:10.1016/j.annemergmed.2017.12.007PubMedGoogle ScholarCrossref
5.
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):663-673. doi:10.1056/NEJMsa1610524PubMedGoogle ScholarCrossref
6.
Hoppe  JA, Kim  H, Heard  K.  Association of emergency department opioid initiation with recurrent opioid use.  Ann Emerg Med. 2015;65(5):493-499.e4. doi:10.1016/j.annemergmed.2014.11.015PubMedGoogle ScholarCrossref
7.
Butler  MM, Ancona  RM, Beauchamp  GA,  et al.  Emergency department prescription opioids as an initial exposure preceding addiction.  Ann Emerg Med. 2016;68(2):202-208. doi:10.1016/j.annemergmed.2015.11.033PubMedGoogle ScholarCrossref
8.
Jeffery  MM, Hooten  WM, Hess  EP,  et al.  Opioid prescribing for opioid-naive patients in emergency departments and other settings: characteristics of prescriptions and association with long-term use.  Ann Emerg Med. 2018;71(3):326-336.e19. doi:10.1016/j.annemergmed.2017.08.042PubMedGoogle ScholarCrossref
9.
Dowell  D, Haegerich  TM, Chou  R.  CDC guideline for prescribing opioids for chronic pain—United States, 2016.  MMWR Recomm Rep. 2016;65(1):1-49. doi:10.15585/mmwr.rr6501e1PubMedGoogle ScholarCrossref
10.
Hoppe  JA, Nelson  LS, Perrone  J, Weiner  SG; Prescribing Opioids Safely in the Emergency Department (POSED) Study Investigators; Prescribing Opioids Safely in the Emergency Department POSED Study Investigators.  Prescribing opioids safely in the emergency department: study I, prescribing opioids safely in the emergency department PSI: opioid prescribing in a cross section of US emergency departments.  Ann Emerg Med. 2015;66(3):253-259.e1. doi:10.1016/j.annemergmed.2015.03.026PubMedGoogle ScholarCrossref
11.
Chang  AK, Bijur  PE, Esses  D, Barnaby  DP, Baer  J.  Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: a randomized clinical trial.  JAMA. 2017;318(17):1661-1667. doi:10.1001/jama.2017.16190PubMedGoogle ScholarCrossref
12.
Chua  KP, Brummett  CM, Waljee  JF.  Opioid prescribing limits for acute pain: potential problems with design and implementation.  JAMA. 2019;321(7):643-644. doi:10.1001/jama.2019.0010PubMedGoogle ScholarCrossref
13.
Bateman  BT, Choudhry  NK.  Limiting the duration of opioid prescriptions: balancing excessive prescribing and the effective treatment of pain.  JAMA Intern Med. 2016;176(5):583-584. doi:10.1001/jamainternmed.2016.0544PubMedGoogle ScholarCrossref
14.
Strayer  RJ, Motov  SM, Nelson  LS.  Something for pain: responsible opioid use in emergency medicine.  Am J Emerg Med. 2017;35(2):337-341. doi:10.1016/j.ajem.2016.10.043PubMedGoogle ScholarCrossref
15.
Barrett  TW, Bellew  SD.  What role has emergency medicine played in the opioid epidemic? partner in crime or canary in the coal mine? answers to the March 2018 journal club questions.  Ann Emerg Med. 2018;72(2):214-221. doi:10.1016/j.annemergmed.2018.03.018PubMedGoogle ScholarCrossref
16.
Griggs  CA, Schulz  CJ.  A changing landscape of opioid prescribing in emergency medicine.  Am J Emerg Med. 2019;37(2):327-328. doi:10.1016/j.ajem.2018.10.042PubMedGoogle ScholarCrossref
17.
Cordell  WH, Keene  KK, Giles  BK, Jones  JB, Jones  JH, Brizendine  EJ.  The high prevalence of pain in emergency medical care.  Am J Emerg Med. 2002;20(3):165-169. doi:10.1053/ajem.2002.32643PubMedGoogle ScholarCrossref
18.
Todd  KH, Ducharme  J, Choiniere  M,  et al; PEMI Study Group.  Pain in the emergency department: results of the pain and emergency medicine initiative (PEMI) multicenter study.  J Pain. 2007;8(6):460-466. doi:10.1016/j.jpain.2006.12.005PubMedGoogle ScholarCrossref
19.
US Surgeon General.  Facing Addiction in America: The Surgeon General’s Spotlight on Opioids. US Dept of Health and Human Services; 2018.
20.
Medicine use and spending in the US: a review of 2017 and outlook to 2022. IQVIA. Published April 19, 2018. Accessed January 10, 2020. https://www.iqvia.com/insights/the-iqvia-institute/reports/medicine-use-and-spending-in-the-us-review-of-2017-outlook-to-2022
21.
 Optimizing the treatment of acute pain in the emergency department.  Ann Emerg Med. 2017;70(3):446-448. doi:10.1016/j.annemergmed.2017.06.043Google Scholar
22.
Zhu  W, Chernew  ME, Sherry  TB, Maestas  N.  Initial opioid prescriptions among US commercially insured patients, 2012-2017.  N Engl J Med. 2019;380(11):1043-1052. doi:10.1056/NEJMsa1807069PubMedGoogle ScholarCrossref
23.
Barnett  ML, Zhao  X, Fine  MJ,  et al.  Emergency physician opioid prescribing and risk of long-term use in the Veterans Health Administration: an observational analysis.  J Gen Intern Med. 2019;34(8):1522-1529. doi:10.1007/s11606-019-05023-5PubMedGoogle ScholarCrossref
24.
Hoppe  JA, McStay  C, Sun  BC, Capp  R.  Emergency department attending physician variation in opioid prescribing in low acuity back pain.  West J Emerg Med. 2017;18(6):1135-1142. doi:10.5811/westjem.2017.7.33306PubMedGoogle ScholarCrossref
25.
Megale  RZ, Deveza  LA, Blyth  FM,  et al.  Efficacy and safety of oral and transdermal opioid analgesics for musculoskeletal pain in older adults: a systematic review of randomized, placebo-controlled trials.  J Pain. 2018;19(5):475.e1-475.e24. doi:10.1016/j.jpain.2017.12.001PubMedGoogle ScholarCrossref
26.
Grasso  MA, Dezman  ZDW, Grasso  CT, Jerrard  DA.  Opioid pain medication prescriptions obtained through emergency medical visits in the Veterans Health Administration.  J Opioid Manag. 2017;13(2):77-84. doi:10.5055/jom.2017.0371PubMedGoogle ScholarCrossref
27.
Janakiram  C, Fontelo  P, Huser  V,  et al.  Opioid prescriptions for acute and chronic pain management among Medicaid beneficiaries.  Am J Prev Med. 2019;57(3):365-373. doi:10.1016/j.amepre.2019.04.022PubMedGoogle ScholarCrossref
28.
Barnaby  DP, Chertoff  AE, Restivo  AJ,  et al.  Randomized controlled trial of intravenous acetaminophen versus intravenous hydromorphone for the treatment of acute pain in the emergency department.  Ann Emerg Med. 2019;73(2):133-140. doi:10.1016/j.annemergmed.2018.06.019PubMedGoogle ScholarCrossref
29.
Moshfegh  J, George  SZ, Sun  E.  Risk and risk factors for chronic opioid use among opioid-naive patients with newly diagnosed musculoskeletal pain in the neck, shoulder, knee, or low back.  Ann Intern Med. 2019;170(7):504-505. doi:10.7326/M18-2261PubMedGoogle ScholarCrossref
30.
Ringwalt  C, Shanahan  M, Wodarski  S,  et al.  A randomized controlled trial of an emergency department intervention for patients with chronic noncancer pain.  J Emerg Med. 2015;49(6):974-983. doi:10.1016/j.jemermed.2015.03.004PubMedGoogle ScholarCrossref
31.
Braden  JB, Russo  J, Fan  MY,  et al.  Emergency department visits among recipients of chronic opioid therapy.  Arch Intern Med. 2010;170(16):1425-1432. doi:10.1001/archinternmed.2010.273PubMedGoogle ScholarCrossref
32.
Todd  KH, Cowan  P, Kelly  N, Homel  P.  Chronic or recurrent pain in the emergency department: national telephone survey of patient experience.  West J Emerg Med. 2010;11(5):408-415.PubMedGoogle Scholar
33.
Bernard  AM, Wright  SW.  Chronic pain in the ED.  Am J Emerg Med. 2004;22(6):444-447. doi:10.1016/j.ajem.2004.07.026PubMedGoogle ScholarCrossref
34.
Pletcher  MJ, Kertesz  SG, Kohn  MA, Gonzales  R.  Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments.  JAMA. 2008;299(1):70-78. doi:10.1001/jama.2007.64PubMedGoogle ScholarCrossref
35.
Heins  JK, Heins  A, Grammas  M, Costello  M, Huang  K, Mishra  S.  Disparities in analgesia and opioid prescribing practices for patients with musculoskeletal pain in the emergency department.  J Emerg Nurs. 2006;32(3):219-224. doi:10.1016/j.jen.2006.01.010PubMedGoogle ScholarCrossref
36.
Marra  EM, Mazer-Amirshahi  M, Mullins  P, Pines  JM.  Opioid administration and prescribing in older adults in US emergency departments (2005-2015).  West J Emerg Med. 2018;19(4):678-688. doi:10.5811/westjem.2018.5.37853PubMedGoogle ScholarCrossref
37.
Vu  JV, Howard  RA, Gunaseelan  V, Brummett  CM, Waljee  JF, Englesbe  MJ.  Statewide implementation of postoperative opioid prescribing guidelines.  N Engl J Med. 2019;381(7):680-682. doi:10.1056/NEJMc1905045PubMedGoogle ScholarCrossref
38.
Illinois Prescription Monitoring Program. Accessed January 10, 2020. https://www.ilpmp.org
39.
Dowell  D, Haegerich  TM, Chou  R.  CDC guideline for prescribing opioids for chronic pain—United States, 2016.  JAMA. 2016;315(15):1624-1645. doi:10.1001/jama.2016.1464PubMedGoogle ScholarCrossref
40.
Poon  SJ, Greenwood-Ericksen  MB.  The opioid prescription epidemic and the role of emergency medicine.  Ann Emerg Med. 2014;64(5):490-495. doi:10.1016/j.annemergmed.2014.06.016PubMedGoogle ScholarCrossref
41.
Weiner  SG, Perrone  J, Nelson  LS.  Centering the pendulum: the evolution of emergency medicine opioid prescribing guidelines.  Ann Emerg Med. 2013;62(3):241-243. doi:10.1016/j.annemergmed.2013.02.028PubMedGoogle ScholarCrossref
42.
Bohnert  ASB, Guy  GP  Jr, Losby  JL.  Opioid prescribing in the United States before and after the Centers for Disease Control and Prevention’s 2016 opioid guideline.  Ann Intern Med. 2018;169(6):367-375. doi:10.7326/M18-1243PubMedGoogle ScholarCrossref
43.
Andereck  JW, Reuter  QR, Allen  KC,  et al.  A quality improvement initiative featuring peer-comparison prescribing feedback reduces emergency department opioid prescribing.  Jt Comm J Qual Patient Saf. 2019;45(10):669-679. doi:10.1016/j.jcjq.2019.07.008PubMedGoogle Scholar
44.
Deyo  RA, Hallvik  SE, Hildebran  C,  et al.  Association between initial opioid prescribing patterns and subsequent long-term use among opioid-naïve patients: a statewide retrospective cohort study.  J Gen Intern Med. 2017;32(1):21-27. doi:10.1007/s11606-016-3810-3PubMedGoogle ScholarCrossref
45.
Bohnert  AS, Valenstein  M, Bair  MJ,  et al.  Association between opioid prescribing patterns and opioid overdose-related deaths.  JAMA. 2011;305(13):1315-1321. doi:10.1001/jama.2011.370PubMedGoogle ScholarCrossref
46.
Hser  YI, Saxon  AJ, Mooney  LJ,  et al.  Escalating opioid dose is associated with mortality: a comparison of patients with and without opioid use disorder.  J Addict Med. 2019;13(1):41-46. doi:10.1097/ADM.0000000000000458PubMedGoogle ScholarCrossref
47.
Pollack  CV  Jr, Diercks  DB, Thomas  SH,  et al.  Patient-reported outcomes from a national, prospective, observational study of emergency department acute pain management with an intranasal nonsteroidal anti-inflammatory drug, opioids, or both.  Acad Emerg Med. 2016;23(3):331-341. doi:10.1111/acem.12902PubMedGoogle ScholarCrossref
48.
Derry  S, Moore  RA, Gaskell  H, McIntyre  M, Wiffen  PJ.  Topical NSAIDs for acute musculoskeletal pain in adults.  Cochrane Database Syst Rev. 2015;(6):CD007402. doi:10.1002/14651858.CD007402.pub3PubMedGoogle Scholar
49.
Motov  S, Masoudi  A, Drapkin  J,  et al.  Comparison of oral ibuprofen at three single-dose regimens for treating acute pain in the emergency department: a randomized controlled trial.  Ann Emerg Med. 2019;74(4):530-537. doi:10.1016/j.annemergmed.2019.05.037PubMedGoogle ScholarCrossref
50.
Levy  B, Paulozzi  L, Mack  KA, Jones  CM.  Trends in opioid analgesic-prescribing rates by specialty, US, 2007-2012.  Am J Prev Med. 2015;49(3):409-413. doi:10.1016/j.amepre.2015.02.020PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Original Investigation
    Emergency Medicine
    March 25, 2020

    Temporal Factors Associated With Opioid Prescriptions for Patients With Pain Conditions in an Urban Emergency Department

    Author Affiliations
    • 1Medical Student, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
    • 2Department of Biomedical Engineering, Northwestern University, Evanston, Illinois
    • 3Department of Statistics, Northwestern University, Evanston, Illinois
    • 4Center for Translational Pain Research, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
    • 5Anesthesiology and Medicine (Rheumatology), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
    JAMA Netw Open. 2020;3(3):e200802. doi:10.1001/jamanetworkopen.2020.0802
    Key Points español 中文 (chinese)

    Question  Have emergency department clinicians responded to the opioid epidemic through altering opioid prescription rates?

    Findings  In this cross-sectional study of 556 176 emergency department patient encounters and 70 218 opioid prescriptions within a single emergency department, yearly prescriptions decreased by 66.3% between 2013 and 2018. This decrease was associated with a 71.1% reduction in the number of opioid prescriptions for musculoskeletal pain (back, limb, joint, and neck pain) and lesser, but still marked, decreases for fractures and kidney stones.

    Meaning  Reductions in yearly opioid prescriptions across varying indications appear to be aligned with recognition of the opioid crisis in addition to national, state, and departmental education guidelines.

    Abstract

    Importance  Opioid prescriptions for treatment of pain in emergency departments (EDs) are associated with long-term opioid use. The temporal pattern of opioid prescribing in the context of the opioid epidemic remains unknown.

    Objective  To examine the temporal pattern of opioid prescribing within an ED for varying pain conditions between 2009 and 2018.

    Design, Setting, and Participants  A population-based, cross-sectional study was conducted at the ED of an urban academic medical center. All patients treated within that ED between January 1, 2009, and December 31, 2018, were included.

    Main Outcomes and Measures  The proportion of patients prescribed an opioid for treatment of pain in the ED temporally by condition, condition type, patient demographics, and physician prescriber.

    Results  Between 2009 and 2018, 556 176 patient encounters took place in the ED, with 70 218 unique opioid prescriptions ordered. A total of 316 632 patients (55.9%) were female, 45 070 (42.6%) were of white race, and 43 412 (40.6%) were privately insured; the median age group was 41 to 45 years. Yearly opioid prescriptions decreased by 66.3% (from 16.3 to 5.5 opioids per 100 encounters) between 2013 and 2018, with a yearly adjusted odds ratio (aOR) of 0.808 (95% CI, 0.802-0.814) compared with the prior year. In patients with musculoskeletal pain (back, joint, limb, and neck pain), opioid prescribing decreased by 71.1% (from 36.7 to 10.6 opioids per 100 encounters between 2013 and 2018; aOR, 0.758; 95% CI, 0.744-0.773). In patients with musculoskeletal trauma (fracture, sprain, contusion, and injury), opioid prescribing decreased by 58.0% (from 34.2 to 14.8 opioids per 100 encounters; aOR, 0.811; 95% CI, 0.797-0.824). In patients with nonmusculoskeletal pain (abdominal pain, kidney stone, respiratory distress, and pharyngitis) opioid prescribing decreased by 53.7% (from 20.1 to 9.3 opioids per 100 encounters; aOR, 0.850; 95% CI, 0.834-0.868). Between 2009 and 2018, patients who were black (aOR, 0.760; 95% CI, 0.741-0.779) and those who were Asian (aOR, 0.714; 95% CI, 0.665-0.764) had the lowest odds of receiving an opioid compared with other racial/ethnic groups.

    Conclusions and Relevance  There was a substantial temporal decrease in the number of opioid prescriptions within this ED during the study period. This decrease was associated with substantial relative reductions in opioid prescribing for treatment of musculoskeletal pain compared with fractures and kidney stones.

    ×