Opioid Prescribing from the ED—we can all do more to help

While the opioid epidemic rages on killing more than 47,000 Americans in 2017 alone,¹ our emergency departments are overflowing with patients who have painful conditions, many of whom respond well—specifically in the acute setting—to opioid therapy.

Although we have mountains of data and plenty of mass media headlines outlining the scope of the opioid tragedy, ED based-studies that develop thoughtful/careful interventions, deliver them reproducibly and test them rigorously are exceedingly rare.

I commend McCarthy et al for identifying ED opioid prescribing as an issue in 2014, before it was on many radars. Instead of hand wringing and trotting out one shocking statistic after another and shrugging off responsibility, they asked: how can we—as bedside ED doctors—do better? They went on to ask how combining their bedside improvements in patient education, with post visit interventions both at the pharmacy and in the primary care setting could help deliver safer opioid pain control for patients.

I am impressed with the time and effort it must have taken to create and deploy the reading-level-appropriate informational handout, change the labeling practices of local pharmacies and automate the notification of primary care doctors of a new opioid prescription. They went on to avoid the temptation—which must have been strong—to implement the changes without the rigor of a randomized control trial demands.

As for the results themselves, they highlight the important point that successful collaboration between the ED doctors, pharmacies and local primary care providers—however complicated and uncompensated it might be—is a possible and a worthwhile undertaking. Just like we have trauma coordinators, STEMI committees and dedicated stroke nurses, perhaps every ED should have an opioid committee that works to implement projects aimed at delivering patient-focused improvements in safety and quality.

McCarthy et al data also reminds us that a substantial majority (84%−89.4%) of ED patients prescribed an opioid at discharge use them as directed. Recently published data report that 9% of patients who are prescribed opioids for acute pain in the ER continue to use them at three months and very few (<1%) report using them for causes other than pain relief.² Sadly, when one considers the sheer volume of patients who leave the ED each year with an opioid prescription and the potential life-threating risk of overdose when medications are used incorrectly or in unsafe combinations, the reported levels of misuse are quite concerning.

Perhaps most concerning in this data set is the fact that 28.2—37.3% of patients used their opioid medications with another sedating medication. We know this is a leading risk factor for overdose and mortality.³ As McCarthy et al point out, we should take this on ourselves, as prescribers, to improve. I might quibble with their inclusion of all commonly used antidepressants in this calculation but just including their Tier One co-ingestions (benzodiazepines and other opioids) the rates of co-ingestion are still much too high at 14.62%. While there are indeed cases where patients taking sedating medications will also need opioid pain relief, we must be paying closer attention to patients’ medication lists, using alternatives wherever possible and having a full discussion of risks of co-ingestions with each individual patient.

McCarthy’s work reminds us that our impact at the bedside, in times of stress and pain for patients, may not be the ideal time for them to understand every risk or piece of information we would like for them to know. Their work also adds to a great wealth of data in the behavior health literature that demonstrates that knowledge, on its own, does not always lead to behavior change. In fact, one of the defining criteria of a substance use disorder is continued use despite knowledge of harm.⁴ However challenging bedside education is, we all have a responsibility to review the risks of these high risk prescriptions in an accurate, accessible way with patients and should encourage us to build and use tools that help reinforce important information after patients leave the ED.

Just because we may not be able to stem the tide of the opioid epidemic from the bedside of individual patients does not absolve us of the obligation to do what is within our control to make patients safer. So what can we all take from this article to the bedside? How many of us always, every time check to make sure patients are not on sedating medications before prescribing an opioid? How many of us are discussing that risk with patients? How many of us risk stratify patients for their risk of long-term use or development of a substance use disorder? How many of us tell every patient in clear terms that opioids are habit forming and 9% people will still be using them at 30 days and those using at 30 days have a 9% chance of developing a substance use disorder?⁵ How many of our departments have a reading level appropriate hand out about the risks and appropriate use of opioids? How many of us even know what the label on the pill bottle reads? How many of us go over, in detail, how we want patients to use their pain medications and how much a max daily dose is? How many of us remind patients about safely storing and disposing of their medications?

We, as ED doctors alone, are not going to solve this problem but certainly there is more we can each be doing to help. McCarthy et al reminds us that we need to put forth the effort and gives us a sense of where to start, both at the bedside, and in our hospital systems and communities at large.