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Studies have shown that opioid use is increasing across the country. Abuse is rampant, but so is the misapplication and over-prescribing of opioids by well-meaning physicians. We’ve reviewed four recent papers which can help create a strategy for ED management of this ever-increasing – and often demanding – patient population.

Increasingly, emergency physicians are dealing with the misuse and abuse of opioids. Patients of all ages — presenting with acute, chronic or diverse etiologies of pain — are seeking help and treatment in the ED. The challenge of balancing the benefits and harms in opioid use can be daunting. In the last few months, four studies have been published that focused on this thorny problem of opioid use, as it relates to the elderly, pain relief, non-medical use and overdose death. Based on those studies, we’ve included some practical suggestions for dealing with this thorny issue (see accompanying box).

headache-sidebar1. BMJ, February 2014[1]: “Opioid prescribing by multiple providers in Medicare: retrospective observational study of insurance claims”

Using a random sample of Medicare beneficiaries, these authors reviewed opioid prescriptions filled by this cohort over a single calendar year.  The hope was, of course, that, considering their elevated risks for adverse effects, the elderly would not be receiving undue quantities of opioids and that there was a single provider managing their prescription.

This study dashes those hopes. According to the research, about one-third of the elderly filled an opioid prescription over the course of the study period – with two-thirds receiving more than one prescription.  Among those receiving more than one opioid prescription, less than half maintained continuity with a single provider.  In fact, there was a group of about 143,000 beneficiaries who received a mean number of 15 opioid prescriptions from more than four different providers. Increased frequency of opioid receipt was, not surprisingly, associated with increased opioid-related hospitalization.

Since this study is based solely on claims data, it may or may not be reasonable to conclude that an improper standard of care is at the root of the problem.

2. Journal of Adolescent Health, February 2014[2]:  “Opioid Use Among Adolescent Patients Treated for Headache”

Opioids are rarely the best answer for headache in the emergency department.  While they offer some analgesic relief, they typically are not effective for treating migraines.  Multiple other agents are preferred, and non-prescription agents are first-line abortive therapy.

Apparently, however, this message isn’t getting out.  This review of commercial health plan adolescents found that 48% of members with headache-related emergency department and primary care visits received prescriptions for opioids.   Many of the individuals in this cohort did, however, have multiple visits to providers, and many tried other abortive therapies. Still, nearly 30% of those who received opioids ended up with more than three prescriptions in the one-year study period. 

3. JAMA Internal Medicine, March 2014[3]:  “Sources of Prescription Opioid Pain Relievers by Frequency of Past-Year Nonmedical Use”

This survey of drug use describes the behavior of the 12 million individuals using opioids for non-medical purposes.  A slight majority of the users were male, and most had annual incomes of less than $50,000 a year.  According to the study, individuals who used opioids for non-medical reasons for fewer than 30 days out of the year obtained most of their opioids free from friends or relatives.  However, as the frequency of use increased, users were increasingly likely to obtain their opioids from drug dealers — and physicians. 

This study confirms that prescription drug abuse starts with physicians.  Every single narcotic pill dispensed from a pharmacy – even if the initial indication is appropriate – becomes a possible precursor for abuse.  This study also demonstrates the need for physicians to be acutely aware of quantities dispensed and the ultimate fate of leftover pills.

4. JAMA Internal Medicine, March 2014[4]:  “High-Risk Use by Patients Prescribed Opioids for Pain and Its Role in Overdose Deaths”

Opioid misuse can, of course, be fatal. This snapshot of overdose deaths comes from Tennessee, where deaths increased from 422 to 1059 between 2003 and 2010.  The authors also note, in the four-year period between 2007 and 2011, one-third of the population of Tennessee filled a prescription for opioids. 

The researchers identified specific risk factors for more than half of the deaths based on three criteria.  A patient filling opioid prescriptions from four or more prescribers, four or more pharmacies, or a daily average dose greater than 100 milligrams of morphine equivalence accounted for 55% of all overdose deaths.  Physicians, particularly primary-care internal medicine and family medicine physicians were responsible for most of the increase in opioid prescribing.  Hydrocodone and oxycodone were the most frequently prescribed, while methadone, oxymorphine and fentanyl were most associated with increased risk of death from overdose.

References

1.  Jena AB, Goldman D, Weaver L, Karaca-Mandic P.  Opioid prescribing by multiple providers in Medicare: retrospective observational study of insurance claims.  BMJ. 2014 Feb 19;348:g1393.

 2.  Devries A, Koch T, Wall E, Getchius T, Chi W, Rosenberg A.  Opioid Use Among Adolescent Patients Treated for Headache.  J Adolesc Health. 2014 Feb 8. [Epub ahead of print]

3.  Jones CM, Paulozzi LJ, Mack KA.  Sources of Prescription Opioid Pain Relievers by Frequency of Past-Year Nonmedical Use: United States, 2008-2011.  JAMA Intern Med. 2014 Mar 3. [Epub ahead of print]

4.  Baumblatt JA, Wiedeman C, Dunn JR, Schaffner W, Paulozzi LJ, Jones TF.  High-Risk Use by Patients Prescribed Opioids for Pain and Its Role in Overdose Deaths.  JAMA Intern Med. 2014 Mar 3. [Epub ahead of print]

Ryan Radecki, MD
Author of Emergency Medicine Literature of Note emlitofnote.com

 

Comments   

# M.D.Alex Zotos 2014-05-07 15:00
Great article. I just have a concern about the statement that is quoted as saying that this study "confirms that prescription abuse starts with doctors". Addiction is a disease that some have predisposition to and while some doctors may be the initial fuse they are not the cause. Most patient have already been abusing prescription drugs from family members or they have had polysubstance abuse in the past. Physicians must take great care by limiting the amount prescribed, counseling patients on risk of abuse, and checking databases. The problem still exists that these patients don't have any viable alternative with no money going towards treatment of opiate dependency.
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# RE: Opioids: Misuse and Abuse WILLIAM E. MALIHA MD 2014-05-07 16:06
I am to old to be subtle. For decades, physicians were accused of not adequately treating pain and were urged to use more opiates as they are generally considered safe and effective for pain management. Suddenly, government and academics are hot and bothered about drug use by our society where about half of our children are raised by single parent families, marijuana is legalized and cities are giving out heroin needles to save on the costs of HIV treatment. So now government has decided that physicians are over prescribing opiates. 143,000 Medicare patients receiving 15 prescriptions of opiates per year tell us nothing. Nearly 45 million people are on Medicare. Thus one in over 300 fits this profile. How many have cancer, how many are living with severe pain syndromes of one type or another. My own rheumatologist has suggested opiates for me for severe psoriatic arthritis. I refused because I personally prefer not live my life in a haze but that does not mean they are not indicated. How many of those Emergency Department scripts for opiates are for just 5 or so doses. In my former busy Emergency Department practice I used to see severe trauma or kidney stones every day. Were these not indications for opiates. And who says that opiates are not indicated for migraines that don't resolve with other medications. All of this commiserating about prescribing habits is just another example of a shotgun style attempt at government solutions for problems that government caused with other social solutions. Are there physicians who abuse their prescribing privileges? Are there patients who shop for narcotics. Of course there are. But there are also 5-10% of society who are alcoholic. to skewer the entire medical profession for inappropriate prescribing habits is ridiculous. The real question is why are so many members of our society needing these medications and why do third party carriers not adequately pay for ongoing counseling and psychotherapy. Fix those issues and you solve the problem.
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# RE: Opioids: Misuse and Abuse Dr. Cynic 2014-05-07 16:42
"In the absence of laboratory or radiogrqphicall y identified pathology there is never a good excuse to give a patient an opiate. The sole exception to this rule is the major trauma patient with visually identifiable bodily damage."
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# DOBrenda Jacobsen 2014-05-09 19:07
The greatest issue is the current arena of "patient satisfaction." If you appropriately limit/withhold opiates (as I often do), the recipient of that measure complains to administration. Too many complaints and you're out of a job. Opiates are OFTEN abused and hoarded and we do need to cut back.
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