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EDs Not Worst Offenders in Increased Opioid Prescribing, Related Mortality

LOS ANGELES – Emergency physicians have gotten a bad rap related to the dramatic increase in opioid prescriptions and unintentional deaths from painkillers, according to a new study.

The truth is that emergency departments prescribe significantly lower doses and numbers of pills for non-cancer pain than do office-based practices, according to researchers from the Leonard D. Schaeffer Center for Health Policy & Economics at the University of Southern California. The study was published recently in the Annals of Emergency Medicine.

Earlier this year, investigators from George Washington University reported in a study published in Academic Emergency Medicine that the rates of opioid prescribing in EDs shot up during a recent 10-year period, far exceeding the increase in visit rates for painful conditions.

Between 2001 and 2010, the percentage of overall emergency department visits in which an opioid analgesic was prescribed increased from 20.8% to 31%, according to that study. The increase in prescription rates was especially dramatic for some opioid painkillers, including Dilaudid, which went up 668.2%, according to the analysis of data from the National Hospital Ambulatory Medical Care Survey.

At the same time, the percentage of visits for painful conditions during the period only increased by 4%, from 47.1% in 2001 to 51.1% in 2010, the authors reported.

The new study suggested, however, that there was more to the story than those statistics revealed, pointing out that “high-dose opioid prescribing is rare in the ED setting (1 in 400 ED opioid prescriptions are for ≥100 MME) compared with office settings (1 in 39 office prescriptions for opioids are for ≥100 MME).”

The University of Southern California researchers also noted that, in response to a recent study identifying high-dose prescribing as an independent risk factor for opioid death, many state chapters of the American College of Emergency Physicians have developed safe opioid prescribing guidelines for EDs.

Calling the ED contribution to this epidemic “incompletely characterized,” the researchers said they sought to quantify strength of opioid prescriptions and frequency of high-dose prescriptions from the ED compared to other care sites. To do so, they analyzed the Medical Expenditure Panel Survey (1997-2011), a nationally representative sub-survey of the annual National Health Interview Survey.

A determination was made for each filled prescription, including where it was generated and exactly how much opioid was prescribed; patient records with ICD-9 codes indicating a history of malignancy were excluded. Researchers also created a model to predict the proportion of high-dose prescriptions, defined as exceeding 100 morphine milligram equivalent (MME), focused on site-of-care.

Based on review of 44,313 unique individuals -- mean age 48 and 63% female -- receiving 164,406 opioid prescriptions during the study period, results indicate that the average opioid prescription originating from EDs was for 44% fewer pills than prescriptions from office visits. In addition, the average compound prescribed from the ED had 17% lower MME than those from office visits.

While 1.9% of all opioid prescriptions from EDs were for more than 100 MME daily, ED prescriptions still were much less likely to be for greater than 100 MME per day compared with medical office settings, according to the report.

“EDs prescribe markedly lower doses and numbers of pills for non-cancer pain than office-based practices. Given the very low rate of high-dose prescribing from the ED, policy efforts to reduce risky opioid prescribing should not focus on ED settings,” study authors conclude.