By Mark Gold, MD
Drug overdoses are the leading cause of accidental mortality in the United States (U.S.) – in 2015 63.1% of all overdoses involved an opioid. While physician over-prescribing is only one part of the problem, opioid prescribing is closely associated with available opioids for misuse, diversion and ultimately higher rates of opioid misuse and death. Emergency Departments have become a place where overdoses are reversed and increasingly, where opioid use disorder (OUD) treatment begins. Although ED providers write fewer opioid scripts on average for their patients as compared to orthopedic and other surgical specialties, they are key influencers of other medical providers due to their pivotal role in OUD interventions.1 They also see a high volume of patients with substance use disorders. This makes them a critical juncture in efforts to not only reverse overdoses but to decrease excessive or unnecessary prescription of opioid medications by changing their protocols and prescribing practices. A recently published report evaluated the impact of sharing individual prescribing data amongst ED physicians as a way to improve prescribing practices in ED’s and reduce opioid overdose and misuse among their patients.
Opioid Prescribing in Emergency Departments
Opioids pose unique risks to the patients whom they are prescribed to, and despite their increased risk, opioid painkillers were not correlated with lower moderate-to-severe musculoskeletal pain six weeks post-discharge from the emergency department.2 After recent discussion amongst scientists about opioid overprescribing, they have suggested procedure-specific prescribing recommendations. These may help guide clinicians who are overprescribing opioids after surgery to safer and more appropriate prescribing practices.3 Multidisciplinary, patient-centered consensus guidelines for more procedures are feasible and may serve as a tool in combating the opioid crisis. One reason for this is that researchers also found that “opioid naïve” patients who had been prescribed opioids were more likely to still be taking opioid painkillers prescribed outside of the ED a full year later. This concerned the researchers, who acknowledge that high prescribing rates of opioid pain medication in emergency departments may also be linked with high rates of opioid misuse and may have a correlation on initiation to, and overdose on, illicit as well as licit opioids.4 Given these trends, the researchers posit that reducing the prescription of opioid analgesics in EDs may lower the incidence of overdose due to both licit and illicit opioids.
Reducing Overprescribing: Methods and Proposed Solutions
Due, in part, to the fact that physicians often underestimate their own prescribing, the researchers hypothesized that sharing individual and prescribing data between peer physicians would lower their likelihood of prescribing opioids – and they were right.5 In this 2018 study, which was conducted in the ED of an institution in Massachusetts over the course of a year, patients were prescribed opioids at a lower rate - and prescribed fewer pills per prescription - when their physicians were shown the group and individual prescribing data.
This study, despite its limitations, supports the concept that a transparency-based intervention on sharing individual and group opioid prescribing data in an ED setting is correlated to a decrease in the per-capita rate of prescriptions written for patients upon discharge. Similar approaches make sense for other prescribers of opioids.
The authors have highlighted how emergency physicians can impact the availability of opioid prescriptions and the influence the expectations of patients regarding receiving opioid medications upon discharge from the ED. Surgical specialties have been recently studied. For all 20 surgical procedures reviewed the minimum number of opioid tablets recommended by the panel was zero. Ibuprofen was recommended for all patients unless medically contraindicated.6 Overall, patients who had the procedures voted for lower opioid amounts than surgeons who performed them. Even though emergency physicians generally prescribe a very limited and small number of pills, they are in a unique position to impact a large number of patients. Still, feedback loops can be educational like those described here, or more threatening as reported recently where the Medical Board has written to physicians whose prescriptions were involved in an overdose death. No one strategy will solve the OUD and overdose epidemic and Rx-related problems, but incorporating feedback and transparency among physicians about their prescribing practices may help improve them.
D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial. JAMA.
Beaudoin FL, Gutman R, Merchant RC, et al. Persistent pain after motor vehicle collision: comparative effectiveness of opioids vs nonsteroidal anti-inflammatory drugs prescribed from the emergency department- a propensity matched analysis. Pain.
Overton, H.N., Matlaga, B. et al. (2018). Opioid-Prescribing Guidelines for Common Surgical Procedures: An Expert Panel Consensus. Journal of the American College of Surgeons.
Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry.
Davis DA, Thomson MA, Oxman AD, et al. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA.
Bicket, M.C. et al., (2019) Association of new opioid continuation with surgical specialty and type in the United States. The American Journal of Surgery.
Boyle, K. L., Cary, C., Dizitzer, Y., Novack, V., Jagminas, L., & Smulowitz, P. B. (2019). Reduction of opioid prescribing through the sharing of individual physician opioid prescribing practices. The American Journal of Emergency Medicine.
Dr. Mark S. Gold is a teacher of the year, translational researcher, author, mentor and inventor best known for his work on the brain systems underlying the effects of opiate drugs, cocaine and food. Read more by Dr. Gold here.