By Stacey Kusterbeck
Some trauma patients receive short-term, low-potency opioid prescriptions for acute pain in the ED, but there are concerns this could put people at risk for opioid use disorder.
“The ED is a place where many patients and providers are making critical decisions surrounding pain management and whether or not to use opioids,” says Brittany Punches, PhD, RN, CEN, FAEN, associate professor at The Ohio State College of Nursing.
Punches and colleagues wanted to see if ED opioid analgesic exposure was linked to subsequent at-risk opioid use.1 They analyzed 872 adults who visited one of 29 EDs for a traumatic event. At-risk opioid use occurred within three months of the visit in 33 out of 620 patients without opioid analgesic exposure, four out of 16 with an opioid prescription only, 17 out of 146 patients with opioid administration only, and 12 out of 90 patients who received an opioid prescription and took the medication in the ED.
“ED providers must make rapid decisions to manage their patients’ pain. Each of the persons enrolled in this study had experienced a trauma of some sort,” Punches says.
Patients who received opioids in the ED (without any prescription) were two times more likely to develop at-risk opioid use. Patients who received a prescription (without taking any opioids in the ED) were five times more likely to develop at-risk opioid use vs. patients who did not receive opioid prescriptions. These findings suggest opioids, while sometimes required for pain, may increase a patient’s risk for developing opioid use disorder.
“Conversations about risk, including alternatives to opioids, are one [tactic] for mitigating risk in the ED,” Punches says.
Another group of researchers studied the most effective ways to quickly identify opioid use disorder in the ED.2 “We know that EDs are an important point of contact for people with opioid use disorder. An emergency room visit can be a turning point where people become open to receiving treatment,” says Izabela Annis, the study’s lead author and senior data analyst at UNC Eshelman School of Pharmacy in Chapel Hill.
Annis and colleagues analyzed 345,728 ED visits that were logged between 2016 and 2018. They found 1.16% of those patients had a diagnosis of opioid use disorder. The researchers found a history of opioid use disorder, a history of taking medications for opioid use disorder, and white race were the strongest predictors.
Typical patients with opioid use disorder were smokers with chronic pain, substance use disorders, and psychiatric disorders. Annis and colleagues recommended emergency providers quickly review the electronic health record (EHR) for history of opioid use disorder. “However, documentation of opioid use disorder diagnoses in EHRs is infrequent and inconsistent,” Annis cautions.
Conversations in the department about chronic pain, source of injury, substance use, and psychiatric disorders could help identify patients with opioid use disorder.
“Better identification and referral of patients with opioid use disorder has the potential to enhance the quality and continuity of care that these patients receive, while also reducing reliance on EDs and the crowding that ensues,” Annis offers.
Opioid use, like any other drug or intervention, is based on the ED provider’s assessment of potential risks and benefits.
“Risks of sedation, respiratory depression, and lowering of blood pressure should be weighed against the risks and benefits of easing severe pain,” says Michael Lynch, MD, attending emergency physician and associate professor of emergency medicine at the University of Pittsburgh School of Medicine.
The patient should be monitored appropriately, with doses titrated to optimize analgesic benefit while minimizing associated short-term risks. “The long-term risks of opioid administration in the ED to manage acute pain associated with traumatic injuries are very low,” Lynch says.
In Lynch’s experience, it is unlikely for patients to abruptly develop an opioid use disorder based on a single short-term opioid course prescribed for acute, severe pain from the ED. More commonly, additional prescriptions are offered following the first visit.
“Those additional prescriptions, along with a complex combination of genetics, personal experience, and unrecognized history of or risk factors for substance use disorder, contribute to the progressive development of opioid use disorder,” Lynch explains.
After ED providers underwent targeted education to modify opioid prescribing patterns, the total number of prescriptions declined by 34%, according to a group of researchers at Summit, NJ-based Overlook Medical Center.3 “Opioids may be appropriate for certain patients; however, considering alternatives first may be more appropriate for some patients,” says Deborah Y. Booth, PharmD, MS, BCPS, the study’s lead author and clinical pharmacy specialist in emergency medicine and opioid stewardship co-chair at Overlook Medical Center.
Booth and colleagues reviewed current regulations and evidence-based guidelines to promote behavioral changes with prescribers. “If opioids are prescribed, they should be done so when alternatives are ineffective or contraindicated using short-acting opioids, at the lowest, most effective dose for the shortest duration,” Booth says.
REFERENCES
1. Punches BE, Stolz U, Freiermuth CE, et al. Predicting at-risk opioid use three months after ed visit for trauma: Results from the AURORA study. PLoS One 2022;17:e0273378.
2. Annis IE, Jordan R, Thomas KC. Quickly identifying people at risk of opioid use disorder in emergency departments: Trade-offs between a machine learning approach and a simple EHR flag strategy. BMJ Open 2022;12:e059414.
3. Booth D, Amalfitano C, Forestine A. Changes in opioid prescription rates at discharge after targeted provider education in the emergency department. J Pharm Pract 2022; Nov 13: 8971900221131911. doi: 10.1177/08971900221131911. [Online ahead of print].
Better identification and referral of patients with opioid use disorder could enhance the quality and continuity of care these patients receive, while also reducing reliance on EDs and the crowding that ensues.
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