ED Opiate Rx Risks Long-Term Use
March 14, 2017
Short Attention Span Summary
Are we creating a monster?
Does opioid prescribing in the ED set someone up to become a long-term user? Using Medicare claims data, the authors identified patients with no opiate prescriptions in the preceding 6 months who received one in the ED and compared the odds of long term use in those who received the prescription from physicians in the same hospital who were either high-frequency ED opiate prescribers to those who were low-frequency prescribers. They found the odds of long-term opiate prescription use was greater when a patient received a prescription from a high frequency prescriber. Not that the ED was providing the long-term prescription, but that they may have opened the door to this problem by being a little too free with the narcotic prescriptions. The number needed to harm was 48.
For every 48 patients given a short-term opiate prescription in the ED, 1 became a long-term opiate user. Over-prescribing opiates in the ED may have significant downstream effects and could open the door to long-term opiate use in our patients. The NYT has a great article and interview with the lead author. Reuben Strayer, EM Updates, also has an outstanding analysis.
N Engl J Med. 2017 Feb 16;376(7):663-673. doi: 10.1056/NEJMsa1610524.
1From the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (M.L.B.), the Department of Health Care Policy, Harvard Medical School (A.R.O., A.B.J.), the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital (M.L.B.), and the Department of Medicine, Massachusetts General Hospital (A.B.J.), Boston, and the National Bureau of Economic Research, Cambridge (A.B.J.) – all in Massachusetts.
Increasing overuse of opioids in the United States may be driven in part by physician prescribing. However, the extent to which individual physicians vary in opioid prescribing and the implications of that variation for long-term opioid use and adverse outcomes in patients are unknown.
We performed a retrospective analysis involving Medicare beneficiaries who had an index emergency department visit in the period from 2008 through 2011 and had not received prescriptions for opioids within 6 months before that visit. After identifying the emergency physicians within a hospital who cared for the patients, we categorized the physicians as being high-intensity or low-intensity opioid prescribers according to relative quartiles of prescribing rates within the same hospital. We compared rates of long-term opioid use, defined as 6 months of days supplied, in the 12 months after a visit to the emergency department among patients treated by high-intensity or low-intensity prescribers, with adjustment for patient characteristics.
Our sample consisted of 215,678 patients who received treatment from low-intensity prescribers and 161,951 patients who received treatment from high-intensity prescribers. Patient characteristics, including diagnoses in the emergency department, were similar in the two treatment groups. Within individual hospitals, rates of opioid prescribing varied widely between low-intensity and high-intensity prescribers (7.3% vs. 24.1%). Long-term opioid use was significantly higher among patients treated by high-intensity prescribers than among patients treated by low-intensity prescribers (adjusted odds ratio, 1.30; 95% confidence interval, 1.23 to 1.37; P<0.001); these findings were consistent across multiple sensitivity analyses.
Wide variation in rates of opioid prescribing existed among physicians practicing within the same emergency department, and rates of long-term opioid use were increased among patients who had not previously received opioids and received treatment from high-intensity opioid prescribers. (Funded by the National Institutes of Health.).
PMID: 28199807 [PubMed – indexed for MEDLINE]