Myth Busted: ED Docs Not a Prime Source of Opioid Prescriptions

Marlene Busko

October 27, 2016

LAS VEGAS — Heavy opioid users are much more likely to receive prescriptions from primary care physicians than emergency department (ED) physicians. However, shared care plans that include ED physicians and their primary care colleagues may help decrease drug seeking by such patients, new research shows.

An analysis of opioid prescriptions in the United States during the past decade showed that among people who filled more opioid prescriptions than 95% of the sample, 88% of the prescriptions came from primary care physicians' offices, and only 2.3% of the prescriptions were issued by ED physicians.

"We have this anecdotal experience, this visceral reaction, that [people who use the most opioids] are bouncing around from ER to ER, clogging the system, but the data just don’t support that," study investigator Michael Menchine, MD, associate professor of clinical emergency medicine at the Keck School of Medicine, University of Southern California, Los Angeles, told Medscape Medical News.

"I just don’t think that trying to ratchet back [opioid] prescribing [in EDs] is likely to be effective," he added.

Instead, Dr Menchine suggested that EDs implement mechanisms to identify potential opioid abusers and get them into treatment programs. "That could actually help, not giving them opioids – we already do that," he said.

The findings were presented here at the American College of Emergency Physicians (ACEP) 2016 Scientific Assembly.

ED Docs Not to Blame

Although previous studies have shown that only about 5% of opioid prescriptions come from the ED, the primary source of opioids among heavy users – those who are most likely to die from opioid overdose – was not known, said Dr Menchine.

For the study, the investigators analyzed data from 47,377 individuals who were participants in the nationally representative Medical Panel Expenditure Survey from 1996 to 2012 and who had filled at least one prescription for opioids. Cancer patients were excluded from the study.

Participants reported the locations where prescriptions were filled. Researchers subsequently contacted those pharmacies to determine the type and doses of the prescribed medications. Doses for different prescribed opioids were standardized by through conversion to milligram morphine equivalent (MME) doses.

On average, opioid users took the equivalent of 1900 MMEs/year, with 45% of the prescriptions originating from primary care physicians' offices and 16% from EDs. However, the heaviest users (≥95th percentile) received 27,000 MMEs/year, with "dramatically more" prescriptions coming from primary care physicians' offices, said Dr Menchine.

Commenting on the findings for Medscape Medical News, session moderator Manish N. Shah, MD, from University of Wisconsin, Madison, said the study highlights a popular misperception about opioid prescribing.

"There's been this assumption that all of the opioid prescribing and all of the problems exist in the emergency department and that should be the focus of all attention, but if we do that, we're going to miss the vast majority of opioid prescribing...which occurs in doctors' offices," he said.

Policy makers need to think about all sites where patients can get opioid prescriptions, Dr Shah added.

Echoing these sentiments, Robert D. Glatter, MD, an ED physician at Lenox Hill Hospital, in New York City, who was not involved in the study, told Medscape Medical News that "contrary to popular belief, it is not emergency physicians who ‎are responsible for prescribing large quantities of opioids for patients who end up in the ED with breakthrough pain [or] progression of their painful condition(s)."

Measures to curb opioid prescribing should focus on education for primary care providers to help reinforce criteria for such prescribing, with a shift to alternative medications, such a nerve modulating agents, or even use of nerve blocks, in conjunction with mindfulness, visualization, and yoga when possible, he added.

Curbing Opioid Seeking

A second study, also presented at the ACEP meeting, showed that shared care plans between ED physicians and primary care physicians dramatically curb opioid-seeking behavior.

Presented by Kenneth J Rapp III, MD, from Morristown Medical Center, in New Jersey, the study included 52 drug-seeking patients. The study showed that the average number of visits to the ED dropped from 8.2/year before the plan was implemented to 2.5/year 1 year later to 0.5/year 5 years later.

ED nurses or physicians identified patients suspected of abusing opioids. ED staff then contacted patients' primary care providers to develop a care plan that specified opioid restrictions.

Patients then received a registered letter informing them of the plan, and their hospital charts were flagged to indicate that a care plan was in for those patients.

In all, care plans were developed for approximately 500 patients and were accessible by ED staff.

The investigators randomly selected 60 patients with care plans, for a final study population of 52 patients.

The greatest drop in ED visits occurred in the first year. Another significant drop occurred in year 2, and the visits remained low for 5 years, said Dr Rapp.

"I think all EDs should have a plan to address patients with drug-seeking behavior so that there is a uniform process to deal with this issue ― which is ultimately faced by so many of us on a daily basis," said Dr Glatter. He noted that the ED in his institution has such plans in place.

Dr Shah added that such plans can help reduce opioid abuse through direct patient education and by bringing the issue of patient opioid abuse to the attention of primary care physicians.

American College of Emergency Physicians (ACEP) 2016 Scientific Assembly. Abstracts 201 and 230. Presented October 17, 2016.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.