Medicaid recipients are at moderate risk for conversion to opioid misuse after just one new prescription issued in the ED, according to the authors of a recent study.1

Researchers identified adults with no record of any opioid prescriptions in the previous year who filled a new opioid prescription after they were discharged from an ED in 2014. Of 202,807 ED visits, 23,381 resulted in a new opioid prescription. Of these, 13.7% led to persistent or high-risk opioid prescription fills within 12 months.

“The crux of the ethical issue is that you definitely have people who need help with pain,” says Ken Marshall, MD, assistant professor in the department of emergency medicine at University of Kansas Medical Center.

For many years, ethical concerns regarding undertreatment of pain were emphasized strongly. “It was drilled into our head that we needed to do a better job of managing pain,” Marshall recalls.

Now that the risks of opioid addiction are well-known, physicians have to make some difficult prescribing decisions, Marshall notes. Some patients (e.g., those with psychiatric comorbidities) are known to be at higher risk for addiction. That makes the decision to prescribe more ethically complex. “For physicians, it’s a really difficult balancing act,” Marshall laments. “It’s likely that those people are at risk for having pain undertreated. However, they also are at risk for addiction.”

A patient with a substance abuse disorder may present to the ED with a fractured arm. “If the patient is in recovery, they often will be their own advocate, and you can use some shared decision-making,” Marshall explains. A brief prescription with timely follow-up is one possibility. The best approach is to use as few opioids for as short a time as reasonably possible. “With each increasing day that the prescription lasts, risk increases,” Marshall says.2

Also important: Managing patients’ expectations. Physicians do not always properly convey that living pain-free is not a realistic expectation and that the solution is not to continue opioids indefinitely, Marshall says. He tells patients: “As a doctor, I am obligated to do what’s best for you. Increasing the length of your prescription will put you at higher risk for developing an opioid dependence. This prescription is to try to get you through the worst of it. If you were my sister or mom, this is exactly the amount I would give to you.”

Most people respond positively to this. “That kind of conversation, instead of the patient leaving dissatisfied and angry, can turn it into a much more therapeutic interaction,” Marshall says.

REFERENCES

  1. Meisel ZF, Lupulescu-Mann N, Charlesworth CJ. Conversion to persistent or high-risk opioid use after a new prescription from the emergency department: Evidence from Washington Medicaid beneficiaries. Ann Emerg Med 2019; Jun 20. pii: S0196-0644(19)30310-5. doi: 10.1016/j.annemergmed.2019.04.007. [Epub ahead of print].
  2. 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;66:265-269.