Emergency Physicians Are Not Likely To Prescribe Opioids To Discharged Patients

While some people visit primary care physicians when they’re in pain, others head to the emergency room. With emergency physicians wanting to provide pain relief to their patients, prescribing opioids to discharged patients may seem like the best option to some — but many physicians are refusing to jump the gun too soon.

Published in the Annals of Emergency Medicine, a journal for the American College of Emergency Physicians, a new report, titled “Opioid Prescribing in a Cross Section of US Emergency Departments,” found that only 17% of patients discharged from the emergency department were given prescriptions for opioid pain relievers. The study also concluded that almost all of these prescriptions were immediate-release formulations and an overwhelming majority of them were small pill counts.

Dr. Lewis Nelson, one of the paper’s authors, warned of the adverse effects of prescribing emergency department patients with extended-release painkillers. “Long-acting and extended-release opioids are very dangerous,” he said in an interview. “They are associated with a great risk of overdose and death, as well as addiction and abuse. They are only appropriate for patients already using large amounts of short-acting, immediate-release formulations.”

After studying the files of 3,284 discharged patients from 19 different emergency departments, researchers learned that the most common opioid painkillers prescribed were oxycodone (52.3%), hydrocodone (40.9%) and codeine (4.8%). A little more than 70% of these patients also received an opioid in the emergency department, where the most common painkiller prescribed was oxycodone (49.2%).

“Based to some extent on the nature of the injury or illness, the expectations of the patient, and the ability to provide follow-up care, a physician use his or her clinical judgment to determine which and how much of pain medicine is optimal,” Nelson said. “There are no clear rules, but most clinicians should fall within a scope of decision-making.”

Emergency medicine physicians prescribed opioids for several types of pain. The report found that the most common diagnosis among study participants was musculoskeletal back pain — abdominal pain followed, and then extremity fractures and sprains.

There are other kinds of therapies that are based on the underlying cause of pain recommended by emergency department physicians. “For example, for a broken bone, using ice and immobilizing the affected body part is very helpful at reducing the need for drug therapy,” he said. “Often nonprescription pain medications, such as ibuprofen, are successful. For back pain, light duty, not strict bed rest, and appropriate exercises may suffice, along with nonprescription analgesics.”

“We always try to help patients understand the nature of the pain and the expected clinical course. This helps patients rationalize their expectations for treatment and relief,” Nelson added.

Dr. Andrew Kolodny, who is the chief medical officer at Phoenix House, a drug treatment provider, believes that while the findings in the report are good news for the medical community, there are still some things that still need to be ironed out. “The bad news is that 17% of patients were sent home from the emergency department with a prescription for a drug in the same class as heroin — and that the bulk of the prescribing appears to have been for conditions where opioids were unnecessary,” he said.

“In the midst of an epidemic of opioid addiction fueled by overexposure of our population to opioids, this finding is disturbing,” Kolodny added.

The Centers for Disease Control (CDC) found that there were 16,235 deaths involving prescription opioids in 2013, an increase of 1% from 2012. There were 8,257 heroin-related deaths in 2013, up 39% from 2012. Total drug overdose deaths in 2013 hit 43,982, up 6% from 2012.

Dr. Donald Teater, medical advisor for the National Safety Council, an organization that aims to promote health and safety in the United States, voiced many of the same concerns as Kolodny — and provided another alternative to prescribing prescription painkillers. “Ibuprofen is more effective than oxycodone and the combination of ibuprofen and acetaminophen is much stronger (and safer) than the opioid combination products that are being prescribed,” he said.

“There are many prescribing guidelines for chronic pain and several for acute pain, whether managed in the emergency department, by primary care providers, by dentists, or by other healthcare providers,” Nelson said. “Understanding that even severe acute pain generally resolves to levels not requiring opioids by about three days (sometimes a little longer) will help limit the overprescribing of opioids to alleviate pain. Most of the prescriptions provided by those studied were in the range of about three days.”

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Source: Forbes