Treating pain is a large part of emergency medicine, often involving aggressive treatment to get a patient's pain under control in a timely manner. In fact, up to 42 percent of emergency department (ED) visits are related to painful conditions.
But striking a balance between managing pain effectively and possibly sowing the seed for drug addiction or feeding a pre-existing drug addiction remains challenging.
Drug overdose is the leading cause of accidental death in the United States, with 52,404 lethal drug overdoses in 2015. Opioid addiction is driving this epidemic, with 20,101 overdose deaths related to prescription pain relievers, and 12,990 overdose deaths related to heroin in 2015.
From 1999 to 2008, overdose death rates, sales and substance use disorder treatment admissions related to prescription pain relievers all increased in parallel:
- The overdose death rate in 2008 was nearly four times the 1999 rate.
- Sales of prescription pain relievers in 2010 were four times those in 1999.
- The substance use disorder treatment admission rate in 2009 was six times the 1999 rate.
In 2012, 259 million prescriptions were written for opioids, which is more than enough to give every American adult his or her own bottle of pills.
It is thought that differences in prescribing practices may be linked to long-term opioid use. However, the differences in individual opioid prescribing and implications for long-term opioid use and adverse outcomes in patients remain unknown.
Emergency physicians are one of the top prescribers of opioids nationwide, after family and internal medicine practitioners. To investigate opioid prescribing practices among emergency physicians, researchers performed a retrospective analysis involving Medicare beneficiaries who had an index ED visit from 2008 through 2011 and had not received prescriptions for opioids within six months before that visit.
After identifying the emergency physicians within hospitals who cared for the patients, physicians were categorized as being high-intensity or low-intensity opioid prescribers. Researchers compared rates of long-term opioid use — defined as six months of days supplied — in the 12 months after a visit to the ED among patients treated by high-intensity or low-intensity prescribers, with adjustment for patient characteristics.
The analysis included 215,678 patients who received treatment from low-intensity prescribers and 161,951 patients who received treatment from high-intensity prescribers. The study, published in The New England Journal of Medicine, found that patients who visited high-intensity opioid prescribers were three times as likely to receive a prescription for opioids as those seen by infrequent or low-intensity prescribers in the same hospital.
Those treated by the most frequent prescribers were 30 percent more likely to become long-term opioid users. Also of interest, rates of opioid-related hospital encounters and encounters for fall or fracture were significantly higher in the 12 months after an index ED visit among patients treated by high intensity opioid prescribers than among patients treated by low-intensity opioid prescribers.
Opioid abuse is the fastest-growing drug abuse problem in the U.S. According to study author Anupam Jena, the Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School and an HMS associate professor of medicine and physician at Massachusetts General Hospital, physicians who prescribe opioids need to be conscious that there is a significant risk that the patient could continue to be on an opioid for a long time — even from a single, short initial prescription.
