Kathleen Louden

October 31, 2014

CHICAGO — Emergency departments generate fewer prescriptions for opioid analgesics and are less likely to prescribe high doses for relief of noncancer pain than office-based practices, a new study has found.

"While we are sensitive to the need to develop strategies to reduce opioid abuse, emergency medicine physicians contribute little to these dangerous prescribing practices," said lead investigator Michael Menchine, MD, from the University of Southern California Keck School of Medicine in Los Angeles.

For opioid analgesics, one in every 400 filled prescriptions originating in the emergency department was high dose, compared with one in 39 originating from office-based practitioners, found the research team presenting here at the American College of Emergency Physicians 2014 Scientific Assembly.

Policy efforts to reduce risky opioid prescribing should not focus on emergency department settings, Dr Menchine told Medscape Medical News.

"If we develop a stricter policy in the emergency department, people with a legitimate need for opioids may not be helped," he pointed out.

Dr Menchine and his colleagues analyzed prescription data for 1997 to 2011 obtained from the Medical Expenditure Panel Survey, an analysis from the annual National Health Interview Survey. They excluded patients with a diagnostic code indicating a history of malignancy.

The researchers first determined whether each filled oral opioid prescription originated from an emergency department or an office-based practice. They then used the National Drug Code to determine the exact compound and dose of opioids prescribed, which they converted to morphine-equivalent doses.

They found that 44,313 unique individuals received 164,406 opioid prescriptions during the study period. Mean age of the cohort was 48 years, 63% of the patients were female, and 65% were white.

Fewer Pills in Scripts From Emergency

Prescriptions from emergency departments contained 44% fewer opioid pills that those from office-based practices (P < .001), and the opioid compounds prescribed were, on average, 17% less potent in morphine-milligram equivalent (P < .001).

Overall, 1.9% of opioid prescriptions were considered high dose or high risk (daily equivalent of 100 morphine mg or more). Prescriptions originating from the emergency department were significantly less likely to be high dose than those originating from office-based practices (0.26% vs 2.62%; P < .001)

For their analyses, the researchers grouped medical conditions into categories, such as headache and musculoskeletal pain.

The pattern of less frequent, lower-dose opioid prescribing in emergency departments than in office practices held across a broad range of condition categories, Dr Menchine told Medscape Medical News.

Results Should Not Alter Prescribing Practice

A limitation of the study is the possibility of recall bias with this database, according to session moderator Brendan Carr, MD, from the Department of Health and Human Services Emergency Care Coordination Center.

Dr Menchine said he agrees with Dr Carr that people might not remember prescriptions they received from the emergency department or their primary care provider; however, he said, it is also possible that the results indicate that emergency medicine physicians are underprescribing opioids.

A low percentage of opioid prescribing in the emergency department does not necessarily mean that emergency medicine physicians should increase the number of opioid prescriptions they make, noted a delegate who attended the presentation.

In fact, a recent study found that the percentage of visits to the emergency department resulting in an opioid prescription rose dramatically from 2001 to 2010, with only a modest increase in the rate of visits related to painful conditions (Acad Emerg Med. 2014;21:236-243).

Dr Carr emphasized that the findings from this study should not be used to change prescribing practices because the research did not analyze whether the opioid prescriptions were for medically appropriate reasons.

"We don't know whether the doses of opioids prescribed were for orthopedic surgery or an ankle sprain," he told Medscape Medical News.

Dr Menchine and Dr Carr have disclosed no relevant financial relationships.

American College of Emergency Physicians (ACEP) 2014 Scientific Assembly: Abstract 1. Presented October 27, 2014.

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