EPs might write an opioid prescription just to tide patients over before outpatient follow-up is possible. Yet even that single prescription puts patients at risk for a future opioid overdose, according to a recent analysis.1

In a 2020 study of why patients returned to the ED within 30 days of their index visit, 57% said it was because of pain.2 “Interestingly, we found that only 23% of patients who returned for pain were discharged with an opioid prescription,” says Sophia Sheikh, MD, FACEP, lead author of both studies and clinical assistant professor at the University of Florida School of Medicine — Jacksonville.

Patients who reported a pain score higher than three on the first ED visit were 11 times more likely to receive an opioid prescription. “This led us to wonder what the potential risk for opioid overdose might be in this group of patients who were discharged with a prescription opioid,” Sheikh says, noting 25% of these patients recorded a high predicted probability for opioid overdose within the next six months, based on the Risk Index for Overdose or Serious Opioid-induced Respiratory Depression, a validated tool that calculates risk of overdose.3

Sheikh and colleagues compared this risk in two groups: Those who were already taking opioids for chronic pain before the ED visit vs. those who were not. “We were surprised to see that these groups shared similar predictive factors. There was no difference in overall risk scores between the two groups,” Sheikh reports.

This, despite the fact patients using opioids chronically exhibited more than double the number of predictive factors than patients who were not using opioids. The group already using opioids tended to record heavier weighted predictive factors (e.g., history of mental illness and substance abuse).

Race was a differentiating factor between the two groups. Most people who were using opioids for pain before their ED visit self-identified as African American. This, compared to the mostly Caucasian group of patients who were not using opioids. Previous research has demonstrated racial disparity in opioid administration.4 Considering all these findings, “our study indicates risk stratification measures are needed in the ED setting when prescribing opioids,” Sheikh concludes.

William Hopkins, JD, a partner at Austin, TX-based Spencer Fane, suggests ED providers take several steps before deciding to prescribe opiates. Consider the patient’s history, including potential chemical dependence, as well as whether there are other medications that can be prescribed instead that do not carry the same risk as opioids. Check prescription drug monitoring programs to find out if the patient already has received prescriptions for opioids. Engage in a detailed conversation with the patient about the possibility of addiction and abuse before securing informed consent.

All this clinical evaluation and medical decision-making should be documented in the patient record. If it is, says Hopkins, “the doctor, the ED, and the hospital are on pretty solid ground in defending themselves in an eventual lawsuit based on the later addiction or abuse by a patient.”

It always is possible the patient or family could sue the ED, alleging that prescribing opioids caused overdose or addiction. “That is going to be a difficult case to prove,” Hopkins notes.

Assuming the use of opioids is clinically justified, the rationale is clinically documented, and the patient has provided informed consent, the plaintiff would have a hard time establishing causation.

Legal problems are more likely if the ED failed to ensure the prescription was not given to someone the ED or hospital knew (or should have known) either had chemical dependency problems, was susceptible to addiction or abuse issues, or had a contraindication. Otherwise, says Hopkins, “even with the prescription being given, what the patient does with the medication after he or she has left the hospital is not the responsibility of the ED or the hospital.”


  1. Sheikh S, Booth-Norse A, Holden D, et al. Opioid overdose risk in patients returning to the emergency department for pain. Pain Med 2021 Feb 8;pnab047. doi: 10.1093/pm/pnab047. [Online ahead of print].
  2. Sheikh S, Booth-Norse A, Smotherman C, et al. Predicting pain-related 30-day emergency department return visits in middle-aged and older adults. Pain Med 2020;21:2748-2756.
  3. Zedler BK, Saunders WB, Joyce AR, et al. Validation of a screening risk index for serious prescription opioid-induced respiratory depression or overdose in a US commercial health plan claims database. Pain Med 2018;19:68-78.
  4. Meghani SH, Byun E, Gallagher RM. Time to take stock: A meta-analysis and systematic review of analgesic treatment disparities for pain in the United States. Pain Med 2012;13:150-174.