Opioid overuse doesn't begin in the ER, study finds

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When it comes to emergency room physicians, there's a perception that they hand out opioids "like candy," said Mayo Clinic researcher Molly Jeffery.

That perception, though, is wrong.

Jeffrey, the scientific director for the Mayo Clinic Division of Emergency Medicine Research and author of a recent study on opioid prescriptions , said that you're less likely to be overprescribed opioids in the ER than in your family doctor's office.

"There's definitely a sense among physicians in other specialties and the general public that in the emergency department, they just hand them out like candy," Jeffery said. "It didn't square with what the physicians that I've worked with have experienced clinically, and also other emergency department physicians I've talked to."

The researchers found that opioid prescriptions from the emergency departments were written for a shorter duration and smaller dose than those written by primary care physicians or surgeons or dentists after a procedure.


The prescriptions the study looked at were for acute, or short-term pain. Using data from OptumLabs Data Warehouse, the researchers analyzed 5.2 million administrative claims from 2009 to 2015. None of the patients had received an opioid prescription in the past six months.

ER prescriptions, better outcomes

The study by the numbers:

— Prescriptions for commercially insured patients at the ER were 44 percent less likely to exceed the recommended three-day supply than those written elsewhere.

— ER patients with acute pain were 46 percent less likely to progress to long-term opioid use than those who received their prescription elsewhere.

— Patients in the ER were also 38 percent less likely to exceed a daily dose of 50 milligrams of morphine equivalent.

— More than 40 percent of opioid prescriptions in a non-ER setting exceeded a seven-day supply.

In 2016, the Centers for Disease Control and Prevention advised against prescribing more than a three-day supply or 50 milligrams of morphine equivalent per day for acute pain. Patients should rarely require more than a seven-day prescription for short-term pain, the CDC recommended.


The study did not expect many of the prescriptions to exceed 50 milligrams of morphine equivalent per day, considering that the patients studied were all opioid naive, or had not received an opioid prescription recently.

One in five prescriptions in a non-ED setting exceeded 50 MME for commercially-insured patients, according to the study. The number dropped slightly to one in six prescriptions for Medicare patients.

'Surprised by the amount we saw'

A dose of 50 morphine milligram equivalents is high for an opioid naive patient, Jeffery said. "If you are not taking opioids regularly, 50 MME should knock you out," she said. "I mean, that's a huge dose. The reason we used that dose in our study is that there isn't really a good rule of thumb out there about where people should start — the idea is just that you're supposed to start low. … We really didn't expect to see much of it at all, so we were surprised by the amount that we saw."

Patients who received their prescription from the ED were also less likely to progress to long-term use. The study found a strong association between receiving a prescription that did not align with the CDC's guidelines and progression to long-term use. The risk of long-term use was about four-time higher for "non-concordant" prescriptions, which would have lasted more than three days, exceeded 50 milligrams of morphine equivalent per day, and/or prescribed long-acting opioids, which release into the body over a greater period of time.

Long-term use does not necessarily lead to addiction, but chronic use can cause dependence on opioids, Jeffery said.

If a dependent patient suddenly stopped taking opioids, they would feel sick and experience withdrawal symptoms. However, their functionality is not impaired and they do not feel the same need for the drugs as an addicted patient.

"Chronic use might still be considered problematic just because of what they have to go through to get the drugs, because of scheduling," Jeffery said. "Also, opioids can have a lot of bad effects on the body, in terms of things like constipation, respiratory depression, so even if you're using them but you're not addicted, it can still be a difficult thing. And so avoiding chronic use could be a good thing for a lot of people."


Baselines needed

The next step in researching opioid guidelines will be to come up with baselines for opioid prescriptions that cut down on the amount of variance between practices and settings.

"If you talk to a surgeon and you ask them, 'How many days should people need after knee surgery?' they say, 'I have no idea,'" Jeffery said. "So some places have put something into effect that says, 'This is what we do as a practice. We give people 'X' number of days at 'X' dose of 'X' drug, and if they need more, we give them more at that time. And I think that's the way it's going to become."

The ideal dose will vary depending on the injury, Jeffrey said, since people with sprained ankles will have a different recovery period than those coming out of elective surgery.

"I think a lot of people are concerned about the emphasis on reducing access to opioids and a lot of people are worried that patients are going to be left to suffer," she said. "Nobody wants patients to suffer needlessly, and healthcare providers in particular - they go into this business because they want to help people. But the United States uses so much more opioids than other countries."

A 2014 Express Scripts report said although the U.S. only claims about five percent of the world's population, we consume about 80 percent of the opioid supply.

"Opioid use doesn't have to be the way it is in the United States, and it's not the case that we either need to be giving them out like we do now, or we need to be holding them back and making people suffer," Jeffery said. "There is something in between."

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