Editor’s Note: This is the seventh part of an ongoing series on what emergency physicians can do to combat the opioid epidemic. 

The opioid epidemic initially revolved around abuse of prescription opioids. Since then, the epidemic has evolved, with the majority of deaths now associated with fentanyl and other synthetic opioids. Still, the majority of people initiate opioid use with prescription opioids before switching to illicit, and potentially more dangerous, drugs.¹ As such, physician prescribing habits continue to be scrutinized. Not only is this evident from articles in the lay press but also with guidelines such as those from the Centers for Disease Control and Prevention (CDC) or hospital organizations.^2,3 In some situations, laws were even passed governing prescribing practices. For instance, in Missouri, a seven-day prescribing limit for acute pain was passed during the latest legislative session.⁴

This scrutiny has led to considerable debate regarding emergency physicians’ prescribing practices and their association with long-term opioid use—and potentially abuse. The easy answer is to keep patients opioid naive when possible. After all, you can’t get addicted if you’re never exposed. Resources are available to help emergency physicians appropriately manage pain in situations where they should avoid opioids. The ACEP Pain Management and Addiction Medicine Section has developed the Managing Acute Pain (MAP) bedside tool (acep.org/map) that can be used in real time.

Of course, there are still times when an emergency physician will need to prescribe an opioid. While scoring systems such as the Opioid Risk Tool (ORT) are readily available on your smartphone and easy to use, they are limited. Sure, a high score should probably make you think twice, but a low score doesn’t eliminate the chance of developing a substance use disorder; this is the crux of the problem. Even though the rate of developing an opioid use disorder is low, we simply don’t know who is going to be fine and who will start down the deadly and destructive path toward addiction.

This is exemplified by the current U.S. Surgeon General, Jerome Adams, MD, MPH. Dr. Adams is an incredibly accomplished physician and public health official. Yet his brother, with similar genetics and raised in similar circumstances, is serving time in federal prison for drug-related crimes due to his substance use disorder.⁵

How Dangerous Are Prescriptions?

What evidence is there that a prescription from the emergency department is going to lead patients down this path? It’s an important question. The emergency department certainly can’t be the source for the majority of prescriptions when compared to internists, family medicine physicians, and pain physicians. However, this doesn’t mean we don’t need to prescribe responsibly. A study published in the New England Journal of Medicine in 2017 investigated this by reviewing claims data from a national sample of Medicare patients.⁶ The authors explored individual prescribing practices among emergency physicians in the same practice to determine if their prescribing was associated with long-term opioid use over the next year. Emergency physicians were separated into “high-intensity” and “low-intensity” prescribers based on the total number of prescriptions and total number of pills prescribed.

The authors found the high-intensity group was 3.3 times more likely to prescribe opioids than the low-intensity group (7.3 percent versus 24.1 percent, P<0.001). Shockingly, this corresponded to a number needed to harm of 49. Or, to put another way, for every 49 prescriptions written, one resulted in long-term use.

There were multiple and significant limitations that have been discussed elsewhere—most important, long-term use does not equal addiction and the prescriptions themselves were not necessarily inappropriate.⁷ Still, this study is not unique in associating new prescriptions in opioid-naive patients with long-term use and is not the only ED-based study to do so.^8-10 A similar study from the CDC also concluded that the probability of long-term use increased starting on day three of the prescription.¹¹ This was also a review of opioid-naive patients in a large claims database and has many of the same limitations as the New England Journal of Medicine study. Other non-ED-based studies also demonstrate long term persistence of between 5 and 10 percent following an initial prescription.^12,13 Once again, long term use does not equal addiction. However, even factoring in their limitations, these findings are important.

Possible Solutions

What is the emergency physician who is concerned about contributing to long-term use—and potentially addiction—but still believes that an opioid is indicated to do? The good news is that evidence shows patients may only need a very short course of opioids for many conditions.

A recent study offered another solution. It looked at the use of digital pills to evaluate ingestion patterns of ED patients.¹⁴ Digital pills are gel caps containing a medication (in this case, oxycodone) and a biosensor. In the stomach, the gel cap is dissolved, releasing the pill and activating the biosensor. A reader is attached by a sticker to the abdominal wall and transmits ingestion data to a cloud-based server. A convenience sample of opioid-naive patients diagnosed with an acute fracture was included.

Only 15 patients completed the study, but what it found was still very interesting. Patients only required a mean of six pills (range of three to nine pills), with nearly 82 percent of the dose taken in the first 72 hours. Nearly half of patients stopped taking opioids by day three. Patients who required operative repair did use more medication (median of eight pills with a range of six to 11) but required small dosages by 24 hours. Importantly, 12 of the 15 patients reported that their pain was well controlled.

A study evaluating opioid requirements following surgery also suggests that patients’ pain can be controlled with smaller amounts of opioids.¹⁵ While there were multiple limitations, the authors determined that the median number of opioids consumed following laparoscopic cholecystectomy, appendectomy, colectomy, hernia repairs, small bowel resections, and vaginal hysterectomies was fewer than 10 tablets. To be balanced, some procedures such as an abdominal hysterectomy required more. Perhaps as interesting, the authors discovered that the quantity of pills prescribed had the strongest association with opioid consumption (0.53 pills consumed for every one prescribed [95% CI, 0.40–0.65]), which was stronger than the association with patient-reported pain in the week following the procedure. Availability of follow-up appointments and other patient-centered factors still need to be considered when determining the prescription duration.

While emergency physicians aren’t responsible for the current epidemic or the majority of opioid prescriptions, our actions may still have long-term repercussions. The good news is that it appears we can still achieve appropriate analgesia while limiting patients’ opioid exposure. For most patients, prescribing between three and four days of opioids, or approximately 10 to 15 pills in addition to non-opioid analgesics for acute pain, should be enough. Of course, patient-specific circumstances and follow-up availability should be factored into prescribing practices.

Dr. Schwarz is associate professor of emergency medicine and medical toxicology section chief at Washington University School of Medicine in St. Louis.

Dr. Waller is a fellow at The National Center for Complex Health and Social Needs and managing partner at Complex Care Consulting LLC.

References

1. https://www.cdc.gov/drugoverdose/data/heroin.htmlHeroin overdose data. Centers for Disease Control and Prevention websit. Accessed Feb. 22, 2019.
2. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain–United States, 2016. JAMA. 2016;315(15):1624-1645.
3. Opioid use in Missouri: opioid prescribing guidelines. Missouri Hospital Association website. Accessed Feb. 22, 2019.
4. S 826, 99th Leg, 2nd Sess (Mo 2018). Accessed Feb. 22, 2019.
5. Joseph A. The surgeon general and his brother: a family’s painful reckoning with addiction. STAT website. Accessed Feb. 22, 2019.
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7. Schwarz E. Unpacking the opioid blame game. Emergency Physicians Monthly website. Accessed Feb. 22, 2019.
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10. Butler MM, Ancona RM, Beauchamp GA, et al. Emergency department prescription opioids as an initial expsoure preceding addiction. Ann Emerg Med. 2016;68(2):202-208.
11. Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use – United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017;66(10):265-269.
12. Marcusa DP, Mann RA, Cron DC, et al. Prescription opioid use among opioid-naive women undergoing immediate breast reconstruction. Plast Reconstr Surg. 2017;140(6):1081-1090.
13. Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017;152(6):e170504.
14. Chai PR, Carreiro S, Innes BJ, et al. Oxycodone ingestion patterns in acute fracture pain with digital pills. Anesth Analg. 2017;125(6):2105-2112.
15. Howard R, Fry B, Gunaseelan V, et al. Association of opioid prescribing with opioid consumption after surgery in Michigan. JAMA Surg. 2018:e184234.