Emergency Department Opioid Prescribing Practices for Chronic Pain: a 3-Year Analysis

Introduction: Canadians are the second largest consumers of prescription opioids per capita in the world. Emergency physicians tend to prescribe stronger and larger quantities of opioids, while family physicians write the most opioid prescriptions overall. These practices have been shown to precipitate future dependence, toxicity and the need for hospitalization. Despite this emerging evidence, there is a paucity of research on emergency physicians’ opioid prescribing practices in Canada. The objectives of this study were to describe our local emergency physicians’ opioid prescribing patterns both in the emergency department and upon discharge, and to explore factors that impact their prescribing decisions. Methods: Emergency physicians from two urban, adult emergency departments in St. John's, Newfoundland were anonymously surveyed using a web-based survey tool. All 42 physicians were invited to participate via email during the six-week study period and reminders were sent at weeks two and four. Results: A total of 21 participants responded to the survey. Over half of respondents (57.14%) reported that they “often” prescribe opioids for the treatment of acute pain in the emergency department, and an equal number of respondents reported doing so “sometimes” at discharge. Eighty-five percent of respondents reported most commonly prescribing intravenous morphine for acute pain in the emergency department, and over thirty-five percent reported most commonly prescribing oral morphine upon discharge. Patient age and risk of misuse were the most frequently cited factors that influenced respondents’ prescribing decisions. Only 4 of the 22 respondents reported using evidence-based guidelines to tailor their opioid prescribing practices, while an overwhelming majority (80.95%) believe there is a need for evidence-based opioid prescribing guidelines for the treatment of acute pain. Sixty percent of respondents completed additional training in safe opioid prescribing, yet less than half of respondents (42.86%) felt they could help to mitigate the opioid crisis by prescribing fewer opioids in the emergency department. Conclusion: Emergency physicians frequently prescribe opioids for the treatment of acute pain and new evidence suggests that this practice can lead to significant morbidity. While further research is needed to better understand emergency physicians’ opioid prescribing practices, our findings support the need for evidence-based guidelines for the treatment of acute pain to ensure patient safety.

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Opioid Prescribing Practices in Chronic Pain Management: Guidelines Do Not Sufficiently Influence Clinical Practice

Journal of Pain ◽

10.1016/j.jpain.2009.03.019 ◽

2009 ◽

Vol 10 (10) ◽

pp. 1051-1057 ◽

Cited By ~ 22

Author(s):

Timothy W. Victor ◽

Nancy A. Alvarez ◽

Errol Gould

Keyword(s):

Chronic Pain ◽

Clinical Practice ◽

Pain Management ◽

Chronic Pain Management ◽

Prescribing Practices ◽

Management Guidelines ◽

Opioid Prescribing

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What physicians need to implement safer opioid prescribing: A qualitative study

Journal of Opioid Management ◽

10.5055/jom.2019.0538 ◽

2019 ◽

Vol 15 (6) ◽

pp. 479-485

Author(s):

Allison Navis, MD ◽

Mary Catherine George, PhD ◽

Maya Scherer, MPH ◽

Linda Weiss, PhD ◽

Yosuke Chikamoto, PhD ◽

...

Keyword(s):

Chronic Pain ◽

Communication Strategies ◽

Insurance Coverage ◽

Patient Specific ◽

Future Research ◽

Successful Implementation ◽

Prescribing Practices ◽

Open Communication ◽

Opioid Prescribing ◽

Control And Prevention

Introduction: In response to the US opioid epidemic, the Centers for Disease Control and Prevention issued a guideline (CDCG) for prescribing opioids for chronic pain. Successful implementation of the CDCG requires identification of the information, skills, and support physicians need to carry out its recommendations. However, such data are currently lacking.Methods: The authors performed one-on-one interviews with nine practicing physicians regarding their needs and perspectives for successful CDCG implementation, including the perceived barriers, focusing on communication strategies. Interviews were audio recorded, transcribed, and a thematic qualitative analysis was performed.Findings: Three major themes were identified: communication, knowledge, and information technology (IT). Physicians reported that open communication with patients about opioids was difficult and burdensome, but essential; they shared their communication strategies. Knowledge gaps included patient-specific topics (eg, availability of/insurance coverage for non-opioid treatments) and more general areas (eg, opioid dosing/equivalencies, prescribing naloxone). Finally, physicians discussed the importance of innovation in IT, focusing on the electronic medical record for decision support and to allow safer opioid prescribing within the time constraints of clinical practice.Discussion: These qualitative data document practical issues that should be considered in the development of implementation plans for safer opioid prescribing practices. Specifically, healthcare systems may need to provide opioid-relevant communication strategies and training, education on key topics such as naloxone prescribing, resources for referrals to appropriate nonpharmacologic treatments, and innovative IT solutions. Future research is needed to establish that such measures will be effective in producing better outcomes for patients on opioids for chronic pain.

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Opioid analgesic use after ambulatory surgery: a descriptive prospective cohort study of factors associated with quantities prescribed and consumed

BMJ Open ◽

10.1136/bmjopen-2020-047928 ◽

2021 ◽

Vol 11 (8) ◽

pp. e047928

Author(s):

Christopher W Shanahan ◽

Olivia Reding ◽

Inga Holmdahl ◽

Julia Keosaian ◽

Ziming Xuan ◽

...

Keyword(s):

Chronic Pain ◽

High Risk ◽

Drug Use ◽

Opioid Analgesic ◽

Safety Net ◽

Opioid Consumption ◽

Secondary Outcome ◽

Prescribing Practices ◽

Opioid Prescription ◽

Opioid Prescribing

ObjectivesTo prospectively characterise: (1) postoperative opioid analgesic prescribing practices; (2) experience of patients undergoing elective ambulatory surgeries and (3) impact of patient risk for medication misuse on postoperative pain management.DesignLongitudinal survey of patients 7 days before and 7–14 days after surgery.SettingAcademic urban safety-net hospital.Participants181 participants recruited, 18 surgeons, follow-up data from 149 participants (82% retention); 54% women; mean age: 49 years.InterventionsNone.Primary and secondary outcome measuresTotal morphine equivalent dose (MED) prescribed and consumed, percentage of unused opioids.ResultsSurgeons postoperatively prescribed a mean of 242 total MED per patient, equivalent to 32 oxycodone (5 mg) pills. Participants used a mean of 116 MEDs (48%), equivalent to 18 oxycodone (5 mg) pills (~145 mg of oxycodone remaining per patient). A 10-year increase in patient age was associated with 12 (95% CI (−2.05 to –0.35)) total MED fewer prescribed opioids. Each one-point increase in the preoperative Graded Chronic Pain Scale was associated with an 18 (6.84 to 29.60) total MED increase in opioid consumption, and 5% (−0.09% to –0.005%) fewer unused opioids. Prior opioid prescription was associated with a 55 (5.38 to –104.82) total MED increase in opioid consumption, and 19% (−0.35% to –0.02%) fewer unused opioids. High-risk drug use was associated with 9% (−0.19% to 0.002%) fewer unused opioids. Pain severity in previous 3 months, high-risk alcohol, use and prior opioid prescription were not associated with postoperative prescribing practices.ConclusionsParticipants with a preoperative history of chronic pain, prior opioid prescription, and high-risk drug use were more likely to consume higher amounts of opioid medications postoperatively. Additionally, surgeons did not incorporate key patient-level factors (eg, substance use, preoperative pain) into opioid prescribing practices. Opportunities to improve postoperative opioid prescribing include system changes among surgical specialties, and patient education and monitoring.

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Changes in Initial Opioid Prescribing Practices After the 2016 Release of the CDC Guideline for Prescribing Opioids for Chronic Pain

JAMA Network Open ◽

10.1001/jamanetworkopen.2021.16860 ◽

2021 ◽

Vol 4 (7) ◽

pp. e2116860

Author(s):

Jason E. Goldstick ◽

Gery P. Guy ◽

Jan L. Losby ◽

Grant Baldwin ◽

Matthew Myers ◽

...

Keyword(s):

Chronic Pain ◽

Prescribing Practices ◽

Opioid Prescribing

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Qualitative insights into the opioid prescribing practices of Australian GP

Family Practice ◽

10.1093/fampra/cmz083 ◽

2019 ◽

Vol 37 (3) ◽

pp. 412-417

Author(s):

Pallavi Prathivadi ◽

Chris Barton ◽

Danielle Mazza

Keyword(s):

Chronic Pain ◽

Research Network ◽

World Health ◽

Evidence Based ◽

Opioid Use ◽

Prescribing Practices ◽

Opioid Prescribing ◽

Attitudes And Practices ◽

Factors Influencing ◽

Age Related

Abstract Background Over the last three decades, Australian opioid-prescribing rates and related morbidity and mortality have dramatically increased. Opioids are frequently prescribed by general practitioners (GPs) to manage chronic non-cancer pain, despite evidence-based recommendations from the Centre for Disease Control, National Institute for Health and Care Excellence and World Health Organization widely cautioning their use. Little is known about the factors influencing the opioid prescribing decisions of Australian GPs, especially when not evidence based. Objective To explore the opioid prescribing knowledge, attitudes and practices of Australian GPs. Methods Semi-structured interviews with 20 GPs recruited from the Monash University practice-based research network in metropolitan, southeastern Melbourne. Thematic analysis was used to identify emergent themes. Data were managed using QSR NVivo. Ethics approval was granted by Monash University. Results Three key themes emerged. GP attitudes towards opioid use for chronic pain varied by age of patient and goals for therapy. Use of opioids for elderly patients was positively perceived. GPs were reluctant to use opioids in younger patients due to fears of addiction and difficulty weaning. GPs felt obliged to prescribe opioids recommended by specialists, even if they believed the opioids were unsafe. Conclusion This study identified and described the patient-centred nature of GP opioid prescribing decisions. Patient age and perceived age-related opioid harm were important factors influencing prescribing decisions. Future work should inform interventions that value GP autonomy while still encouraging a collaborative inter-speciality approach to managing chronic pain patients with opioids.

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Orthopedic Surgeon Decision-Making Processes for Postsurgical Opioid Prescribing

Military Medicine ◽

10.1093/milmed/usz397 ◽

2019 ◽

Vol 185 (3-4) ◽

pp. e383-e388 ◽

Cited By ~ 1

Author(s):

Jason A Kopp ◽

Ashley B Anderson ◽

Jonathan F Dickens ◽

Andrew C Graf ◽

Crevan O Reid ◽

...

Keyword(s):

Chronic Pain ◽

Quality Improvement ◽

Orthopedic Surgery ◽

Orthopaedic Surgery ◽

Risk Mitigation ◽

Influential Factors ◽

Quality Improvement Project ◽

Prescribing Practices ◽

Improvement Project ◽

Opioid Prescribing

Abstract Introduction Acute pain and chronic pain are significant burdens in the Department of Defense, compounded by the ongoing opioid crisis. Given the ubiquity of (leftover) opioid prescriptions following orthopedic surgery, it is essential to identify feasible and acceptable avenues of opioid risk mitigation efforts. The present quality improvement project builds on recent studies by evaluating factors related to opioid prescribing decisions in a sample of orthopedic surgery providers. Materials and Methods This quality improvement project received a Determination of Not Research and was conducted through a collaboration between the Department of Orthopaedic Surgery and the Department of Anesthesiology and Pain Management at Walter Reed National Military Medical Center. Providers in the Department of Orthopaedic Surgery completed an anonymous online survey assessing opioid prescribing education, factors influencing prescribing practices, opioid-safety practices, and perspectives on potential opioid safety initiatives. Results In total, 39 respondents completed surveys. There was variability in exposure to different types of opioid prescribing education, with some variation between attendings/physician assistants and residents. Patients’ acute postsurgical pain, using a standardized amount for most patients, and prescription histories were the three most influential factors. Concern of patients running out and fear of patient dissatisfaction were the least influential factors. Respondents commonly reported engagement in promoting nonpharmacological pain management, as well as coordinating with chronic pain providers when applicable, but did not commonly report educating patients on leftover opioid disposal. Respondents indicated that a barrier to opioid risk mitigation was the difficulty of accessing appropriate electronic health record data to inform decisions. Lastly, they reported openness to proposed opioid safety initiatives. Conclusion The results of this quality improvement project identified several target areas for future initiatives focused on improving opioid prescribing practices. This included a provider training program, improved patient education system, increased awareness and use of opioid tracking databases, and development of a standardized (but adaptable per patient characteristics and history) recommended dose for common orthopedic surgeries. Future projects will target tailored development, implementation, and evaluation of such efforts.

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Disparities in Analgesia and Opioid Prescribing Practices for Patients With Musculoskeletal Pain in the Emergency Department

Journal of Emergency Nursing ◽

10.1016/j.jen.2006.01.010 ◽

2006 ◽

Vol 32 (3) ◽

pp. 219-224 ◽

Cited By ~ 100

Author(s):

Janet Kaye Heins ◽

Alan Heins ◽

Marianthe Grammas ◽

Melissa Costello ◽

Kun Huang ◽

...

Keyword(s):

Emergency Department ◽

Musculoskeletal Pain ◽

Prescribing Practices ◽

Opioid Prescribing

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Administration of and Prescribing Opioids in Emergency Departments: A Retrospective Study

Kansas Journal of Medicine ◽

10.17161/kjm.vol1413368 ◽

2021 ◽

Vol 14 ◽

pp. 1-4

Author(s):

Casey McNeil ◽

Alma Habib ◽

Hayrettin Okut ◽

Sheryl Beard ◽

Elizabeth Ablah ◽

...

Keyword(s):

Chronic Pain ◽

Drug Overdose ◽

Emergency Departments ◽

The United States ◽

Prescribing Practices ◽

Opioid Prescription ◽

Opioid Medication ◽

Opioid Prescribing ◽

Opioid Administration ◽

Overdose Deaths

Opioid overdose was a cause of 42,249 deaths in the United States in 2016 (13.3 deaths per 100,000) and contributed to 67.8% of all drug overdose deaths in the USA in 2017.1,2 The rate of drug overdose resulting in death in Kansas in 2016 was 11.8 per 100,000, (333 total drug overdose deaths).2 Emergency departments (EDs) are a key intermediary in opioid prescriptions. In 2010, 31% of ED visits nationally resulted in an opioid prescription.3 The number of opioid prescriptions from an ED varies greatly even for a single medical indication. For example, states varied from 40% to 2.8% of patients being prescribed an opioid medication from the ED for ankle sprains among opioid-naive patients treated from 2011 to 2015.4 In Kansas, 35.7% of ankle sprain patients received an opioid prescription from an ED.4 Guidelines for acute pain, including the Alternatives To Opioids protocol (ALTO)5 and the Center for Disease Control and Prevention’s Chronic Pain Guidelines (CDC-CPG)6 are available to guide opioid medication decisions. The ALTO protocol can be used to guide administration and prescription of analgesics for indications that include headache/migraine, musculoskeletal pain, renal colic, abdominal pain, bone fracture, and joint dislocation. The protocol encourages the use of analgesics such as acetaminophen, ibuprofen, and ketorolac prior to opioid administration.5 The CDC-CPG guides the provider into setting goals for pain control, discussing appropriate risks and benefits with the patients, and setting criteria for minimizing long-term opioid use,6 but defers to the American College of Emergency Physician’s 2012 clinical policy guideline for opioid management of chronic pain in the ED. The ACEP recommends against prescribing opioids for acute exacerbation of chronic pain in the ED [Level C recommendation].7 Adopting opioid prescribing guidelines has drastically reduced opioid prescribing rates in some locations.8 For example, a study performed in both a community and an academic medical center tested the implementation of an opioid prescribing guideline that resulted in a decline of opioid prescriptions from 52.7% to 29.8% of patient visits.8 Even in a hospital with less frequent opioid prescribing practices, adopting guidelines has reduced opioid administration in the ED from 22.5% to 17.7%.9 In 2017, 17 states had adopted opioid prescription guidelines10; however, Kansas is not one of those states. Knowing little of opioid prescribing practices in Wichita, Kansas, the purpose of this study was to identify factors that are associated with opioid administration and prescriptions in EDs in Wichita, Kansas, and to evaluate what methods are used by local prescribers to limit opioid administration and prescription in a locality without an opioid prescribing guideline.

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Association of clinical competence, specialty and physician country of origin with opioid prescribing for chronic pain: a cohort study

BMJ Quality & Safety ◽

10.1136/bmjqs-2021-013503 ◽

2021 ◽

pp. bmjqs-2021-013503

Author(s):

Robyn Tamblyn ◽

Nadyne Girard ◽

John Boulet ◽

Dale Dauphinee ◽

Bettina Habib

Keyword(s):

Chronic Pain ◽

Clinical Competence ◽

Primary Care Physicians ◽

Country Of Origin ◽

Prescribing Practices ◽

Female Physicians ◽

Opioid Prescription ◽

Opioid Prescribing ◽

Medical Graduates ◽

Higher Doses

BackgroundAlthough little is known about why opioid prescribing practices differ between physicians, clinical competence, specialty training and country of origin may play a role. We hypothesised that physicians with stronger clinical competence and communication skills are less likely to prescribe opioids and prescribe lower doses, as do medical specialists and physicians from Asia.MethodsOpioid prescribing practices were examined among international medical graduates (IMGs) licensed to practise in the USA who evaluated Medicare patients for chronic pain problems in 2014–2015. Clinical competence was assessed by the Educational Commission for Foreign Medical Graduates (ECFMG) Clinical Skills Assessment. Physicians in the ECFMG database were linked to the American Medical Association Masterfile. Patients evaluated for chronic pain were obtained by linkage to Medicare outpatient and prescription files. Opioid prescribing was measured within 90 days of evaluation visits. Prescribed dose was measured using morphine milligram equivalents (MMEs). Generalised estimating equation logistic and linear regression estimated the association of clinical competence, specialty, and country of origin with opioid prescribing and dose.Results7373 IMGs evaluated 65 012 patients for chronic pain; 15.2% received an opioid prescription. Increased clinical competence was associated with reduced opioid prescribing, but only among female physicians. For every 10% increase in the clinical competence score, the odds of prescribing an opioid decreased by 16% for female physicians (OR 0.84, 95% CI 0.75 to 0.94) but not male physicians (OR 0.99, 95% CI 0.92 to 1.07). Country of origin was associated with prescribed opioid dose; US and Canadian citizens prescribed higher doses (adjusted MME difference +3.56). Primary care physicians were more likely to prescribe opioids, but surgical and hospital-based specialists prescribed higher doses.ConclusionsClinical competence at entry into US graduate training, physician gender, specialty and country of origin play a role in opioid prescribing practices.

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