Opioid Prescribing Rates Down in Emergency Departments

Ben Smith, BA

There was a substantial temporal decrease in opioid prescriptions within an urban academic medical center’s emergency department, according to new study findings.

The reduction was likely due to an alignment with the recognition of the opioid crisis along with national, state, and departmental education guidelines.

Ben Smith, BA, and colleagues from Northwestern University, conducted a study of all patients treated at the Northwestern Memorial Hospital emergency department and Northwestern Memorial Hospital Feinberg Mezzanine emergency room between 2009-2018 to examine the temporal pattern of opioid prescribing within the departments for varying pain conditions. The team also examined the temporal pattern of opioid prescribing at the individual clinician level.

Smith, a medical student at Feinberg School of Medicine at Northwestern University, and the investigative team selected the patient encounters from the Northwestern Medicine Enterprise Data Warehouse. A patient encounter was defined by a unique patient having a unique time and date entered into the database from the electronic health record (EHR). Encounters included self-identified age; race/ethnicity; sex; payer status; opioid prescribed; deidentified physician prescriber; and ICD-9 and 10 codes for each patient.

Hydrocodone plus acetaminophen represented 97.1% of all prescriptions.

The team selected 12 diagnostic conditions: back pain; joint pain; limb pain; neck pain; abdominal pain; fracture; sprain; contusion; other unspecified injury; kidney stone; respiratory distress; pharyngitis. The conditions made up 59.4% of all opioids prescribed.

Overall, there were 556,176 patient encounters who presented at the emergency departments, with 70,218 unique prescriptions ordered. More than half of the patients were female (55.9%), 42.6% were of white race, and 40.6% were privately insured. The median age group was 41-45 years old.

Among the patients with an opioid prescribed, the median age group was 46-50 years old and 55.5% were female, 47.6% were white, and 46% were privately insured.

Yearly opioid prescriptions decreased by 66.3%—from 16.3 to 5.5 opioids per 100 patient encounters—between 2013-2018 (yearly aOR, .808; 95% CI, .802-.814) compared with the prior year.

For patients who had musculoskeletal pain, including back, neck, joint, and limb pain, prescribing decreased by 71.1% from 36.7 to 10.6 opioids per 100 encounters (aOR, .758; 95% CI, .744-.773). Among those with musculoskeletal trauma, such as fracture, sprain, contusion, and injury, prescribing was reduced by 58% from 34.2 to 14.8 opioids per 100 encounters (aOR, .811; 95% CI, .797-.824).

There was a 53.7% decrease in opioid prescribing in patients with nonmusculoskeletal pain like abdominal pain, kidney stone, respiratory distress, and pharyngitis, from 20.1 to 9.3 opioids per 100 encounters (aOR, .85; 95% CI, .834-.868).

Over the study period from 2009-2018, patients who were black (aOR, .76; 95% CI, .741-.779) and those who were Asian (aOR, .714; 95% CI, .665-.764) had the lowest odds of being prescribed an opioid compared to other racial/ethnic groups.

At the clinician level, the analyzed physicians were associated with a similar reduction in prescribing rates.

The findings of the study suggested that substantial decreases in opioids could allow for more selective prescribing for the treatment of acute, self-limited pain in patients with musculoskeletal trauma and kidney stones.

Although the study results were positive, Lewis Nelson, MD, and emergency medicine colleagues from other academic medical centers wrote in an accompanied commentary that emergency physicians should not solely address the potential effectiveness of opioid deprescribing as an isolated metric.

“The specialty, and the health care system overall, must continue to focus on rational and compassionate pain management using the existing toolkit of nonpharmacologic, nonopioid, and opioid therapies, while balancing the potential risks of (opioid use disorder), hyperalgesia, and overdose,” the emergency medicine physicians wrote.

The study, “Temporal Factors Associated With Opioid Prescriptions for Patients With Pain Conditions in an Urban Emergency Department,” was published online in JAMA Network Open.