Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use: What Barnett 2017 Means

Barnett and his colleagues demonstrated that opioid-naive patients who presented to an emergency department and were treated by a high opioid prescriber were more likely to become long term opioid users than those who were treated by a low opioid prescriber.

The purpose of this study was to determine whether one opioid prescription can initiate long term opioid use. This is a difficult question to answer because though plenty of anecdotal evidence suggests yes, addiction has a complex genesis and the vast majority of patients who receive an opioid prescription for acute pain have no serious consequences. However, because developing opioid addiction is often a life-ruining event, and because we count opioid prescriptions in the hundreds of millions, if even a small fraction of patients started on opioids develop addiction as a result of the prescription, the harms to those affected outweigh the analgesic benefit offered to everyone else.

How do you correlate a single variable with an uncommon but extremely harmful, multifactorial adverse event? Prospectively randomizing 100,000 patients is not possible, so we’re confined to retrospective analysis. There are a number of researchers who have done just that [1 2 3 4 5 6 7 8 9 10], and though most of these studies came to a similar conclusion, their methodologies are comparatively weak. For example, linking a single opioid prescription to long-term use suffers from the confounder that patients who receive an opioid prescription are likely in more pain than patients who don’t, so it’s not surprising that they are more likely to go on to recurrent opioid use.

In the absence of a controlled study design, scientists look for a naturally occurring randomizing event, which, if you’re smart enough to identify and analyze it, is an experiment performed accidentally. This is exactly what happens when a patient shows up for emergency care: she is assigned to a provider randomly. Barnett and his group (none of whom are emergency physicians) brilliantly exploited this physician lottery by pairing it with the hugely variant opioid prescribing practice of 27,772 physicians in their sample. Thus the 215,678 patients seen by the highest-prescribing quartile of emergency docs differ from the 151,951 patients seen by the lowest-prescribing quartile of emergency docs only in that the former are more likely to be discharged with an opioid script. It’s as if 377,629 patients were randomized. Because, in effect, they were.

When you randomize 377,629 patients, you can identify small treatment effects, and they did. A patient who sees a high prescriber is slightly (0.35%) more likely to be using opioids one year from now. 0.35% is a small number, and this is concordant with our experience: most folks who get their first opioid script don’t run into trouble. But this study compellingly suggests that some small number–Barnett says 1 in 48, but maybe it’s 1 in 148 or maybe even 1 in 481–are set down the path to opioid misuse from a prescription for pain. This paper is not about implicating emergency medicine, as it has been spun, or even about judging high prescribers vs. low prescribers. As Dr. Barnett said in my correspondence with him, “Fundamentally our paper is about the concept that even one opioid prescription to a naive patient can be associated with long-term use.”

Apart from the strength of the correlation between one opioid prescription and long-term use, it’s hard to imagine that more than 1 in 7 patients discharged from the emergency department should walk out with vicodin, as was found in this study. If you’re looking for resources to help you prescribe more judiciously, readers can start here and listeners/watchers can start here.

Opioid Misuse: Tools for the Emergency Provider


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Pain & The Poppy: Emergency Care During An Addiction Epidemic

Slideset

Pain, Compassion, Addiction, Malingering

How to use opioids and how to not use opioids

Video + Slides (University of Toronto) (35 minutes + questions)

SMACC 2015 Audio (right click to download) (25 minutes)

SMACC 2015 Slideset

SMACC Podcast Page

EM Cases Discussion with Anton Helman and David Juurlink

 

opioid misuse flow

Opioid Discharge Instructions

You are being discharged with a prescription for an opioid pain medication. Opioids are powerful analgesics that can be very effective for pain but also have the potential to harm you.  You should only take opioid pain medications if you are still suffering with pain after you’ve optimized non-medication strategies (rest, position of comfort, ice, heat, etc) and non-opioid medications such as acetaminophen (Tylenol) and ibuprofen (Motrin).  Take opioid pain medications as prescribed; do not take more than prescribed or take the pills in a different way than prescribed.

Opioids often cause constipation, nausea, and itching. Opioids can also cause more dangerous problems such as feeling ill, excessive sleepiness, confusion, and falls. Older people and people with liver or kidney disease are more prone to these harms. You should not drive or perform dangerous work while using opioid pain medications.

If you take too much opioid pain medication, your breathing can slow or even stop, which can be fatal. This is how people die from an opioid overdose.

Opioids can cause acute physical dependence after only a few days, which means that if you take opioid pain medications for a few days and then stop, you might experience withdrawal symptoms such as muscle aches, pain, insomnia, feeling nauseated and ill, depressed, agitated, or anxious, and you might even crave more pills. If you take more opioid pills, these symptoms will be greatly relieved, however this is the beginning of a very dangerous cycle of dependence, which can lead to addiction. If it is possible that you are experiencing acute physical dependence, do not take more opioid pills and discuss the problem with your doctor.

Lastly, once this painful episode is over, dispose of any unused pills–you can take them back to the pharmacy or flush them down the toilet. Leftover opioid pills can be extremely dangerous to children, and are a major source of recreational use, especially among adolescents and young adults.

 

Opioid Misuse Phraseology

My job is to manage your pain at the same time that I manage the potential for some pain medications to harm you.

I know you are in pain and I want to improve your pain, but I believe that opioids are not only the wrong treatment for your pain, but that opioids are the cause of your pain. I think pain medications are harming you, and if you could stop taking them, your pain and your life would improve. Can I offer you resources that will help you stop taking pain medications?

Prescription pain medications, even when used as directed, can cause patients to become dependent, and I’m concerned that the pills we prescribed for you in the past, even though you were using them appropriately, you may now be dependent on them. We can help you break free of that dependence.

My most important job as an emergency doctor is to make sure there’s no emergency, so I would like to do some tests to make sure there’s nothing dangerous happening to you, and also I want to relieve your pain. But you will not receive any opioids while you are here, because I think opioids could be harmful to you.

Here is your prescription. I am not entirely comfortable giving you this prescription because I am concerned that you are being harmed by these pain killers. When you decide that you want to stop using these drugs, and I hope you do, we can help you. Here is a list of resources available to help you stop.

 

opioid-alternatives

 

Opioid Misuse Spectrum

 

John Oliver’s stunningly comprehensive, dead on accurate, often hilarious take: (20 minutes)