Researchers find controversial results after investigating opioid use, misuse after ED visit
Tuesday, September 10, 2019
It is almost universally agreed that opioid prescription in the emergency department (ED) is risky, largely because of the risk of abuse. The results of a recent study suggest the risk of long-term prescription opioid use and potential misuse stemming from ED prescriptions for opioids to treat acute pain is less than some might expect.
When looking at long-term prescription opioid use, most research uses retrospective studies based on the information on filled opioid prescriptions obtained from government databases.
While the studies provide helpful information on the number of opioids prescriptions filled, they cannot determine if the patients ever consumed the opioid. The research also cannot differentiate if the patients used the opioids for new pain or for chronic pain, and if the patients misused the opioids.
Lead author of the study, Raoul Daoust, MD, MSc, and his team wanted to assess opioid use rate and the reasons patients continue to consume opioids three months after discharge from the emergency department with an opioid prescription. They found that opioid use was relatively low three months after discharge from the ED with an opioid prescription.
The researchers conducted the prospective cohort study of 1,316 patients aged 18 years who went to the emergency department of a tertiary care urban center for an acute pain condition. The team followed up by phone with the patients three months after the ED visit and asked about the patients’ opioid consumption in the previous two-week period.
The researchers also inquired about their reasons for consuming opioids for pain related to the initial ED visit, for new and unrelated pain, or for another reason.
Mean age of the participants was 51 years; 47% were female. Mean pain intensity at triage was 7.7, decreasing to 5.2 by discharge from the ED. At discharge from the emergency department, patients received a prescription for a median of 30 tablets of 5 mg of morphine or its equivalent. 94% of patients filled the prescription and 79% consumed opioids during the first two weeks following the ED visit.
Of the 524 study participants questioned at three months, 9% of the patients still used opioids three months after discharge from the ED with an acute pain condition. Of those that continued to use opioids, 91% did so to manage pain — 72% to control initial pain, 19% to manage new pain unrelated to the ED visit, and 9% for another reason.
The researchers also found that participants who used opioids in the two weeks following the ED visit were 3.8 times more likely to consume the painkillers at three months.
The researchers published the results of their study in the August 2019 issue of the journal of the Society for Academic Emergency Medicine (SAEM), Academic Emergency Medicine (AEM).
The Results are Controversial
Most notably, less than 1% consumed opioids for reasons other than pain, suggesting a low level of opioid misuse among patients 3 months after an ED visit.
The results of the study are controversial because they undermine the widely accepted theory that all opioid prescribing — whether for acute pain or chronic pain — is risky.
“The clear and present applied implication for research from Daoust et al is the need to test non-narcotic methods to treat acute pain. The more theoretical research implication is the need to better understand the neurobiology that drives the conversion of acute to chronic pain,” said Jeffrey A. Kline, AEM Editor-in-Chief.
Critics also question the author’s methodology. Gail D'Onofrio, MD, a professor of emergency medicine and chair in the department of emergency medicine at Yale University, says, “Emergency physicians should not be reassured by the authors' findings. The lack of a denominator, poor response rate (56%), and applied definition of misuse are significant limitations. Shah et al (MMWR 2017) demonstrated the escalating probability of continued opioid use among opioid-naïve patients at one and three year if greater than three days were prescribed.”
Daoust is a clinical professor and researcher in the Department of Family Medicine and Emergency Medicine at the University of Montreal. He is known internationally for his work in alcohol and substance use disorders. He has developed and tested interventions for opioids, alcohol and other substance abuse disorders, and has served as a principal investigator on a number of large National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), and Substance Abuse and Mental Health Services Administration (SAMHSA) studies.
Dr. D'Onofrio is also a founding board member of the Board of Addiction Medicine, which the American Board of Specialties has recently recognized as a subspecialty.
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