Opioid Prescribing by Emergency Physicians and Risk of Long-Term Use

TO THE EDITOR:

Barnett et al. (Feb. 16 issue)¹ affirm a key hypothesis: seemingly random clinical exposure to opioids facilitates long-term use, at least among Medicare patients. Without careful inspection, readers may incorrectly interpret this finding to suggest that emergency physicians are key drivers of the opioid epidemic. Nationally, emergency department encounters account for only 5% of all opioids prescribed, even though they constitute more than 10% of all ambulatory visits.²

This study shows that the risk of long-term opioid use after treatment in an emergency department by a “high-intensity prescriber” is small at 1.51%, as compared with a 1.16% risk associated with treatment by a “low-intensity prescriber.” Together these data suggest that interventions in the emergency department to reduce prescribing have a low potential to reduce long-term opioid use. Furthermore, the study is seriously limited, since it does not and cannot compare this effect size against that of providers in other clinical settings where high-dose and long-term opioid prescribing is much more prevalent (e.g., office-based practices that account for >84% of opioid prescriptions).³ Understanding this crucial limitation is key to ensuring that policies do not unjustly focus on opioid prescribing in emergency departments, but rather target the problem of overprescribing of opioids in a comprehensive, multidisciplinary manner.