Alicia Ault

April 30, 2015

Users of prescription opioids for nonmedical reasons make more visits to the emergency department (ED) than people with problems with alcohol or marijuana, a nationally representative survey has shown.

And getting those opioids from physicians is a leading independent predictor of emergency department use in the previous year, according to Joseph Frank, MD, from the VA Eastern Colorado Healthcare System in Denver.

As a practicing primary care physician, Dr Frank says he frequently deals with the challenges and complications of treating pain with and without opioids. Physicians "are increasingly being asked to pay extra attention to how we're using these medications," he explained.

"Our study adds to the evidence of the size and scope of the problem of nonmedical use of prescription pain medications," he told Medscape Medical News.

He presented the findings at the Society of General Internal Medicine 2015 Annual Meeting in Toronto.

Dr Frank and colleagues conducted a serial cross-sectional analysis of data from the National Survey on Drug Use and Health from 2008 to 2013. They assessed the nonmedical use of opioids and the implications of that use in a nationally representative sample of 228,556 noninstitutionalized respondents 18 years and older in the United States.

Survey respondents were asked whether they had used a prescription opioid pain medication "that was not prescribed for you, or that you took only for the experience or feeling it caused."

On the basis of the self-reported responses, Dr Frank's team estimated that, for each of the survey years, 10.5 million (4.6%) adults used opioids for nonmedical reasons. Of those, 840,000 (8.0%) reported nonmedical use on at least 200 days in the previous year.

Tip of the Iceberg

"Given the stigma associated with substance use, there may be under-reporting, which would mean that our estimate of 10.5 million adults with previous-year nonmedical use is an underestimate," Dr Frank told Medscape Medical News.

Respondents who reported previous-year nonmedical use were young (60% were younger than 35), and more likely to be male, white, and uninsured, he reported. The primary source of opioids was cited as one or more physicians by 20% of users. In addition, 14% of users reported experiencing opioid withdrawal symptoms in the previous year.

More adults with previous-year opioid use than adults in the general population visited the emergency department in the previous 12 months (39% vs 27%; P <.001). In fact, previous-year opioid users accounted for 9.4 million emergency department visits annually, which is 7.3% of all annual visits.

On multivariable logistic regression analysis, there was a significant association between previous-year emergency department visits and previous-year opioid use (odds ratio [OR], 1.37; 95% confidence interval [CI], 1.30 - 1.44).

In contrast, there was no association between emergency department visits and alcohol-use disorders (OR, 1.07) or marijuana-use disorders (OR, 1.07).

Predictors of previous-year emergency department visits were at least 200 days of opioid use a year, compared with fewer than 30 days (OR, 1.43; 95% CI, 1.17 - 1.76), withdrawal symptoms (OR, 1.67; 95% CI, 1.44 - 1.95), and having a physician as source (OR, 1.87; 95% CI, 1.60 - 2.19).

Why More ED Use?

Opioid users might be more likely to visit the emergency department than alcohol and marijuana users because they could be seeking treatment for withdrawal symptoms or trying to obtain medications, "which is a unique aspect of this challenge that does not apply to marijuana and alcohol," Dr Frank explained.

Opioid users might also be more likely to experience an overdose.

And users receiving opioids from one or more physician might be "more likely to use them in riskier ways that lead to complications and emergency department visits," he said.

These findings are not surprising, said Andrew Kolodny, MD, chief medical officer of Phoenix House, a national nonprofit addiction treatment agency, and director of Physicians for Responsible Opioid Prescribing.

People taking opioids for at least 200 days a year are "likely to be addicted," he told Medscape Medical News, so it makes sense that they'd be showing up frequently in emergency departments.

Withdrawal can bring on severe anxiety, akin to a panic attack, so users will be desperate, Dr Kolodny explained.

One of the limitations of the study is that it does not include information on whether nonmedical use includes people who take a medication that was not prescribed to them to treat pain, said Dr Frank.

Dr Kolodny said he agree. This is "an excellent survey for drug-use trends, but it's not good for telling us who among those drug users suffers from addiction," he said.

It is "very concerning" that physicians are a source for nonmedical users. This study "could lend support to those advocating for mandatory use of a prescription drug monitoring program," he added.

"A Teachable Moment"

 
This is a complicated problem that will require that we work together across specialties, across healthcare systems, and across state lines.
 

If a person is coming to the emergency department to get pills, "they're not coming in seeking addiction treatment," Dr Kolodny said. However, if they are there because of an overdose, "that's a teachable moment."

"It does look like policymakers and medical societies are beginning to pay attention, so there is some reason to be hopeful," he told Medscape Medical News.

"I think a constructive dialog is already happening among healthcare professionals, who are very aware of the urgency of this problem," said Dr Frank.

"We must continue to support research to understand how and why so many adults are using prescription pain medications nonmedically," he added.

Dr Frank said he will use the findings from this study to inform his practice, including screening for nonmedical use of opioids, and to try to understand withdrawal and how it drives healthcare use.

"This is a complicated problem that will require that we work together across specialties, across healthcare systems, and across state lines," he said.

Dr Frank and Dr Kolodny have disclosed no relevant financial relationships.

Society of General Internal Medicine (SGIM) 2015 Annual Meeting: Abstract 2197865. Presented April 23, 2015.

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