Emergency room physicians vary widely in their opioid prescribing habits – even for similar diagnoses at the same hospital, new research shows.  And this disparity can trigger a course of care that leads some patients to opioid dependence.

An analysis of more than 377,000 ER visits – made by Medicare patients between 2008 and 2011 – illuminates the risks:

• Patients who were assigned to a “high intensity” or frequent opioid prescriber were three times more likely to get an opioid painkiller than other patients with similar health problems.  This was the case even within the same ER.
• Long-term opioid use was “significantly higher” in patients who saw a high-intensity prescriber vs. patients treated by low-intensity prescribers.

The study from the Harvard T.H. Chan School of Public Health and Harvard Medical School was published earlier this year in The New England Journal of Medicine.

“Our work shows that patients who see an ER doctor with a high opioid prescribing rate are more than 30% more likely to develop long-term opioid use over the next year,” says lead author Michael L. Barnett, M.D., Assistant Professor of Health Policy and Management at Harvard and a primary care physician at Brigham and Women’s Hospital in Boston.  “This is related to a higher chance of getting just one prescription, and these patients were not on opioids before they visited the ER.”

An estimated one in 48 people who were prescribed an opioid in the ER and “might not otherwise use opioids” will become a long-term user, the researchers noted.  The consequences can be dire – from opioid-related falls that diminish an older person’s quality of life, to physical dependence and addiction.

“It is a stark reminder that even single prescriptions for an opioid can lead to addiction,” says Howard Mell, M.D., a spokesperson for the American College of Emergency Physicians (ACEP).

Mell, who practices emergency medicine near Chicago, notes that while the risk of addiction from a single opioid exposure is real, the vast majority of those prescriptions occur outside of the ER.  Primary care doctors, for example, prescribe more than 70 percent of opioid pain relievers, according to the National Institute on Drug Abuse.

And follow-up prescriptions by other clinicians who see the patient after an ER visit “are necessary for long-term opioid use to take hold,” the Harvard researchers state.

Since ER doctors are on the front lines of America’s opioid crisis, Mell says they are keenly aware of the problem – and taking steps to minimize addiction risk.

“When you see a story about another teenager who overdosed and died, it was an emergency room doctor who had to break the news to the parents.  It’s probably the worst part of my job,” he says.  “A lot of our current research is on ways not to use narcotics.  We’ve looked at the increased use of non-steroidal anti-inflammatories, or using intravenous lidocaine in cases of renal colic (kidney stone pain).  I think the overwhelming majority of emergency physicians right now are using opioids as a last resort.”

High Intensity Prescribers:  Opioids for 1 in 4 Patients

The Harvard study examined the prescribing patterns of more than 14,000 ER physicians from 2008 to 2011.  Doctors were classified as “high-intensity” prescribers if they gave opioids to one out of every four patients; the “low-intensity” prescribers gave opioids to one out of every 14 patients.

Even within the same hospital, rates of prescribing varied widely.  Doctors treating similar conditions in the ER sent between 7.3 percent and 24.1 percent of patients home with opioids, according to the study.  Researchers were limited in their ability to quantify drug overuse, since they couldn’t observe whether an opioid prescription was appropriate.

When long-term health outcomes were analyzed, the doctor’s prescribing patterns made a difference.

Patients seen by high-intensity prescribers were 30 percent more likely to be chronic opioid users when researchers followed up a year later (chronic opioid use was defined as being supplied at least 180 days of opioids. Medicare beneficiaries who were taking opioids for chronic pain, prior to their ER visit, were excluded from the study).

Hospital visits for falls or fractures related to opioid use were “significantly higher” among patients treated by the high-intensity opioid prescribers, the study said.

Another finding:  older adults treated by low-intensity prescribers did not show increased re-visits to the ER, which indicates that their pain may have been adequately treated.

“I think ER physicians can use these results to better communicate the risks of opioid medications to patients – particularly the risk of long-term use or falls/fractures – and present non-opioid pain medicine as a reasonable alternative treatment strategy as often as reasonable,” says Barnett, the study’s lead author.  “Clearly, there is already substantial variation in how ER physicians prescribe, so many physicians could likely offer opioids less frequently without undertreating pain.”

Still Soaring:  Overdose Deaths

The study’s findings arrive amid the nation’s worsening drug epidemic.  As many as 65,000 deaths from drug overdose are projected for 2016, according to a recent New York Times analysis (official government figures won’t be available until Dec. 2017).  That would be an all-time high and the largest annual increase in U.S. overdose fatalities.

Most overdoses involve an opioid such as heroin, illicitly manufactured fentanyl products, or prescription narcotics such as Oxycodone, according to the Centers for Disease Control.

Source:  The New York Times

While people over 65 have the lowest rate of death from drug overdose, several studies point to a growing prevalence of opioid misuse among older adults.  A report by Stanford University, published in JAMA Psychiatry in 2016, notes the Medicare population “has among the highest and most rapidly growing prevalence of opioid use disorder, with more than 6 of every 1,000 patients diagnosed (vs. 1 of every 1,000 commercially-insured patients) and with hospitalizations increasing 10 percent per year.”

Adults ages 45-54 have the highest rate of drug overdose deaths.  Source:  Centers for Disease Control and Prevention

Older adults are especially vulnerable to falls and fractures that can be triggered by the sedating effects of opioids.  “Multiple studies have shown increased rates of falls, fractures, and death from any cause associated with opioid use in this population,” the Harvard study notes. “Even short-term opioid use may confer a predisposition to these side effects and to opioid dependence.”

Overall, about a third of people ages 65+ will be involved in a fall this year (of any origin)  that reduces quality of life, according to the American College of Emergency Physicians.

No Paradigm for Pain

The inconsistency in ER prescribing patterns is complicated by each patient’s unique medical and genetic history, and how they experience acute pain.

“There is no standard approach to treat acute pain because there are so many diverse causes of acute pain and little evidence to guide physicians’ decisions one way or another,” Barnett says.

Mell notes that on some shifts, “it seems like a Hollywood writer scripted my day, and I have 10 different patients with 10 different conditions – all of which are painful and I have to decide which drug is the most appropriate to use in each case.

“There would be no way to have a guideline, per se, to cover all of the possible instances of acute pain . . . But emergency doctors are the experts at this.  So that’s the good.  That’s what we do.”

He also points to a study showing emergency room doctors are experts at detecting drug-seeking behaviors.  They can often predict who is abusing opioids based on markers such as multiple ER visits for the same complaint, requesting a medication by name, or having symptoms out of proportion to the doctor’s examination.

An ER physician’s background also comes into play when prescribing narcotics.

“We’re all trained differently and because we’re all experts in pain management, everybody’s got a slightly different approach,” Mell says.  “It has to do with when they (doctors) were trained, and how they are dealing with evidence to adapt their practice over time.”

Addressing the profession as a whole, a 2016 article in the New England Journal of Medicine notes that very few medical schools offer adequate training in pain management, and “still fewer offer even one course in addiction.”  The authors – leaders at the National Institute on Drug Abuse and the nonprofit Treatment Research Institute – stress the need for more provider education:

“Many motivated, well-intentioned physicians do not know whether to prescribe opioids for pain management and, if so, which ones and for how long. Still fewer understand the pharmacologic or clinical relationships among tolerance, physical dependence, and addiction. This education is particularly critical for primary care practitioners, who prescribe more than 70% of opioid analgesics.”

In 2016, the Centers for Disease Control and Prevention (CDC) issued guidelines for physicians on opioid prescribing.  But as Barnett notes, “there is still lots of room for variation within those guidelines, which primarily address chronic, not acute pain.

“What we know is that every time we prescribe opioids, there is a risk of generating addiction,” Mell says.  To help patients understand those risks, the American College of Emergency Physicians has launched an educational campaign, “Emergency Care for You.”  This includes a flyer on how to properly take opioids if prescribed by an ER doctor, with a reminder that “prolonged use of opioids can actually do the opposite of what they are designed for and create – rather than treat – pain.”

“As a rule, I don’t prescribe opioids other than for truly painful conditions, in very short courses – something like a broken bone,” Mell says.  “And I kind of remind people, ‘it’s going to hurt.  You’re going to be in pain.’”

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Related Resources for Our Readers:

Flyer:  Emergency Care For You campaign

“Pain Management and Opioids in the Emergency Department”

Video:  The 7 Step Challenge to Prevent Falls

From the American College of Emergency Physicians
Article:  Beyond Opiates:  A Whole Body Approach to Managing Chronic Pain