MP15: Predictors of emergency department opioid use and variability of prescribing practices in a large multicenter Canadian cohort

Introduction: Emergency department (ED) opioid prescribing has been linked to long-term use and dependence. Anecdotally, significant opioid practice variability exists between physicians and institutions, but this is poorly defined. Our objective was to collate and analyze multicenter data looking at predictors of ED opioid use and to identify potential areas for opioid stewardship. Methods: We linked administrative and computerized physician order entry (CPOE) data from all four ED's within our municipality over a one-year period. Eligible patients included those with a Canadian Triage and Acuity Scale (CTAS) pain complaint or an arrival numeric rating scale (NRS) pain score of greater than 3/10. Patients with missing demographic or chief complaint data were excluded. Multiple imputation was used for missing NRS pain scores. We performed descriptive analyses of opioid-treated and non-treated patients, followed by a multivariable logistic regression to identify predictors of ED opioid administration. Results: A total of 129,547 patients were studied. The mean age was 47.4 years and 55.4% were female. The median pain score was 6.6 in the no-opioid group and 8 in the opioid group. The most common pain categories were abdominal pain (23%), trauma (18.2%) and chest pain (15.3%). Overall, opioids were prescribed to 34% of patients. The most common CTAS score was CTAS 3 (44%), CTAS 1-2 42%) and CTAS 4-5 (13.9%). Multivariable predictors of opioid-use included the need for admission (adjusted OR 6.57; CI = 6.34-6.79), NRS pain score (aOR 1.24 per unit increase, CI 1.23-1.25), higher numerical CTAS score (aOR 0.89 per unit increase, CI 0.87-0.91), and chief complaints of back (aOR 7.69, CI 7.1-8.1), abdominal (aOR 5.9, CI 5.6-6.2), and flank pain (OR 3.8, CI 3.5-4). Oral opioids were prescribed in 39.8% of back pain presentations and 18.5% received IV opioids. Increasing age was a predictor but sex was not. There were significant institutional differences in opioid prescribing rates, with Hospital B being the least likely to prescribe opioids (aOR 0.82, CI 0.80-0.85) followed by Hospital C (aOR 0.83, CI 0.79-0.86) compared to the reference standard of Hospital A. Hospital D was most likely to prescribe opioids (aOR 1.32, CI 1.27-1.37). Conclusion: Predictors of ED opioid use were characterized using multicenter administrative data. Future research should seek to describe the physician- and site-level factors driving regional variation in opioid-based pain treatment.

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Sublingual Buprenorphine/Naloxone and Multi-Modal Management for High-Risk Chronic Pain Patients

Journal of Clinical Medicine ◽

10.3390/jcm10050973 ◽

2021 ◽

Vol 10 (5) ◽

pp. 973

Author(s):

Shane Kaski ◽

Patrick Marshalek ◽

Jeremy Herschler ◽

Sijin Wen ◽

Wanhong Zheng

Keyword(s):

Chronic Pain ◽

High Risk ◽

Pain Score ◽

Rating Scale ◽

Pain Treatment ◽

Pain Clinic ◽

Sublingual Buprenorphine ◽

Significant Downward Trend ◽

Chronic Pain Patients ◽

Pain Patients

Patients with chronic pain managed with opioid medications are at high risk for opioid overuse or misuse. West Virginia University (WVU) established a High-Risk Pain Clinic to use sublingual buprenorphine/naloxone (bup/nal) plus a multimodal approach to help chronic pain patients with history of Substance Use Disorder (SUD) or aberrant drug-related behavior. The objective of this study was to report overall retention rates and indicators of efficacy in pain control from approximately six years of High-Risk Pain Clinic data. A retrospective chart review was conducted for a total of 78 patients who enrolled in the High-Risk Pain Clinic between 2014 and 2020. Data gathered include psychiatric diagnoses, prescribed medications, pain score, buprenorphine/naloxone dosing, time in clinic, and reason for dismissal. A linear mixed effects model was used to assess the pain score from the Defense and Veterans Pain Rating Scale (DVPRS) and daily bup/nal dose across time. The overall retention of the High-Risk Pain Clinic was 41%. The mean pain score demonstrated a significant downward trend across treatment time (p < 0.001), while the opposite trend was seen with buprenorphine dose (p < 0.001). With the benefit of six years of observation, this study supports buprenorphine/naloxone as a safe and efficacious component of comprehensive chronic pain treatment in patients with SUD or high-risk of opioid overuse or misuse.

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Impact of Legislation on Opioid Prescribing following Hysterectomy and Hysteroscopy in Arizona and Florida

Gynecologic and Obstetric Investigation ◽

10.1159/000519517 ◽

2021 ◽

pp. 1-9

Author(s):

Aakriti R. Carrubba ◽

Amy E. Glasgow ◽

Elizabeth B. Habermann ◽

Amanda P. Stanton ◽

Megan N. Wasson ◽

...

Keyword(s):

Statistical Analysis ◽

Cohort Analysis ◽

Oral Morphine ◽

Interrupted Time Series ◽

Interrupted Time Series Analysis ◽

Opioid Use ◽

Prescribing Practices ◽

Opioid Prescribing ◽

Before And After ◽

Legislative Changes

Objectives: This study aimed to determine the oral morphine equivalents (OMEs) prescribed and refill rates following hysterectomy and hysteroscopy in the setting of opioid prescribing practice changes in 2 states. Design: This is a retrospective cohort analysis consisting of 2,916 patients undergoing hysterectomy or hysteroscopy between July 2016 and September 2019 at 2 affiliated academic hospitals in states that underwent legislative changes in opioid prescribing in 2018. Methods: Participants were identified using the Current Procedural Terminology procedure codes in Arizona and Florida. Hysterectomy was chosen as the most invasive gynecologic procedure, while hysteroscopy was chosen as the least invasive. Medical records were abstracted to find opioid prescriptions from 90 days before surgery to 30 days after discharge. Patients with opioid use between 90 and 7 days before surgery were excluded. Prescriptions were converted to OMEs and were calculated per quarter year. Statistical analysis included Wilcoxon rank sum t tests for OMEs and χ2 t tests for refill rates. Interrupted time-series analysis was used to determine significant change in OMEs before and after legislative change. Statistical analysis was performed using SAS version 9.4 (SAS Institute, Cary, NC, USA). Results: In Arizona, 1,067 hysterectomies were performed; 459 (43%) vaginal, 561 (52.6%) laparoscopic/robotic, and 47 (4.4%) abdominal. There were 530 hysteroscopies. Overall median OMEs decreased from 225 prior to July 2018 to 75 after July 2018 (p < 0.0001). The opioid refill rate remained unchanged at 7.4% (p = 0.966). In Florida, there were 769 hysterectomies; 241 (31.3%) vaginal, 476 (61.9%) laparoscopic/robotic, and 52 (6.8%) abdominal. There were 549 hysteroscopies. Overall median OMEs decreased from 150 prior to July 2018 to 0 after July 2018 (p < 0.0001). The opioid refill rate was similar (7.8% before July 2018 and 7.3% after July 2018; p = 0.739). Limitations: Limitations include involvement of a single hospital institution with a total of 10 fellowship-trained surgeons and biases inherent to retrospective study design. Conclusions: Legislative and provider-led changes coincided with decreases in opioid prescribing after 2018 in both states without increasing rates of refills and showed actual data reflected in the medical record. Gynecologists must actively participate in safe prescribing practices to decrease opioid dependence and misuse.

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Effect of pharmacist-led task force to reduce opioid prescribing in the emergency department

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxz204 ◽

2019 ◽

Vol 76 (22) ◽

pp. 1853-1861

Author(s):

Nicole M Acquisto ◽

Rachel F Schult ◽

Sandra Sarnoski-Roberts ◽

Jaclyn Wilmarth ◽

Courtney M C Jones ◽

...

Keyword(s):

Emergency Department ◽

Task Force ◽

Care Center ◽

Linear Regression Analysis ◽

Tertiary Care ◽

Interrupted Time Series Analysis ◽

Opioid Use ◽

Entire Study ◽

Opioid Prescribing ◽

Reduction Program

Abstract Purpose Results of a study to determine the effect of a pharmacist-led opioid task force on emergency department (ED) opioid use and discharge prescriptions are presented. Methods An observational evaluation was conducted at a large tertiary care center (ED volume of 115,000 visits per year) to evaluate selected opioid use outcomes before and after implementation of an ED opioid reduction program by interdisciplinary task force of pharmacists, physicians, and nurses. Volumes of ED opioid orders and discharge prescriptions were evaluated over the entire 25-month study period and during designated 1-month preimplementation and postimplementation periods (January 2017 and January 2018). Opioid order trends were evaluated using linear regression analysis and further investigated with an interrupted time series analysis to determine the immediate and sustained effects of the program. Results From January 2017 to January 2018, ED opioid orders were reduced by 63.5% and discharge prescriptions by 55.8% from preimplementation levels: from 246.8 to 90.1 orders and from 85.3 to 37.7 prescriptions per 1,000 patient visits, respectively. Over the entire study period, there were significant decreases in both opioid orders (β, –78.4; 95% confidence interval [CI], –88.0 to –68.9; R2, 0.93; p < 0.0001) and ED discharge prescriptions (β, –24.4; 95% CI, –27.9 to –20.9; R2, 0.90; p < 0.001). The efforts of the task force had an immediate effect on opioid prescribing practices; results for effect sustainability were mixed. Conclusion A clinical pharmacist–led opioid reduction program in the ED was demonstrated to have positive results, with a more than 50% reduction in both ED opioid orders and discharge prescriptions.

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Intravenous Paracetamol vs Intranasal Desmopressin for Renal Colic in the Emergency Department: A Randomized Clinical Trial

Pain Medicine ◽

10.1093/pm/pnaa240 ◽

2020 ◽

Vol 21 (12) ◽

pp. 3437-3442

Author(s):

Hamed Basir Ghafouri ◽

Niloofar Abazarian ◽

Mohammadreza Yasinzadeh ◽

Ehsan Modirian

Keyword(s):

Clinical Trial ◽

Emergency Department ◽

Pain Score ◽

Randomized Clinical Trial ◽

Renal Colic ◽

Rating Scale ◽

Pain Scores ◽

Intravenous Paracetamol ◽

Significant Difference ◽

Intranasal Desmopressin

Abstract Objective To evaluate the analgesic efficacy of intranasal desmopressin alone vs intravenous paracetamol in patients referred to the emergency department with renal colic. Design Randomized clinical trial. Setting This study was conducted in the emergency unit of a university hospital. Subjects Patients referred to the emergency room with renal colic. Primary Outcome Effect of intranasal desmopressin in pain relief in comparison with intravenous paracetamol. Methods In this trial, 240 patients diagnosed with renal colic were randomly divided into two groups to compare the analgesic effect of intravenous paracetamol (15 mg/kg) and intranasal desmopressin spray (40 μg). Pain scores were measured by a numeric rating scale at baseline and after 15, 30, and 60 minutes. Adverse effects and need for rescue analgesic (0.05 mg/kg max 3 mg morphine sulphate) were also recorded at the end of the study. Results Three hundred patients were eligible for the study; however, 240 were included in the final analysis. The patients in the two groups were similar in their baseline characteristics and baseline pain scores. The mean pain score after 15 minutes was more reduced and was clinically significant (>3) in the desmopressin group (P < 0.0001). There was no significant difference between mean pain scores in the two groups after 30 minutes (P = 0.350) or 60 minutes (P = 0.269), but the efficacy of the two drugs was significant in terms of pain reduction (>6). Conclusions Our study showed that intranasal desmopressin is as effective as intravenous paracetamol for renal colic pain management; however, significant clinical reduction in pain score occurred faster with intranasal desmopressin.

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P113: Examining emergency physicians’ self-reported opioid prescribing practices for the treatment of acute pain: A Newfoundland perspective

CJEM ◽

10.1017/cem.2020.319 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S105-S106

Author(s):

P. Doran ◽

G. Sheppard ◽

B. Metcalfe

Keyword(s):

Emergency Department ◽

Acute Pain ◽

Oral Morphine ◽

Prescribing Patterns ◽

Evidence Based ◽

Emergency Physicians ◽

Prescribing Practices ◽

Opioid Prescribing ◽

Ensure Patient Safety ◽

Evidence Based Guidelines

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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Assessment of acute pain in trauma—A retrospective prehospital evaluation

Journal of Opioid Management ◽

10.5055/jom.2016.0351 ◽

2016 ◽

Vol 12 (5) ◽

pp. 347 ◽

Cited By ~ 2

Author(s):

Stine Hebsgaard, MD ◽

Anne Mannering, MD ◽

Stine T. Zwisler, MD, PhD

Keyword(s):

Endotracheal Intubation ◽

Severe Pain ◽

Rating Scale ◽

Pain Treatment ◽

Opioid Analgesics ◽

Multiple Injuries ◽

Pharmacological Intervention ◽

Mild Pain ◽

Trauma Population ◽

Opioid Administration

Objective: To elucidate pain treatment with analgesics in a prehospital trauma population.Design: Retrospective database study.Setting: Prehospital data from the anesthesiologist-manned Mobile Emergency Care Unit (MECU) in Odense, Denmark, were extracted and subjected to analysis.Patients: During the period of January 1, 2013 to December 31, 2014, patients with the diagnoses “unspecified multiple injuries,” “examination and observation following traffic accident,” “examination and observation following other accident,” and “commotio cerebri” were included in the analysis.Main Outcome Measures: Evaluation of the application of the pain scale Numeric Rating Scale (NRS). Furthermore, the authors performed a characterization of the patients with mild pain and severe pain according to specific parameters such as pharmacological interventions, opioid consumption, intubation, and others.Results: Nine hundred eighty-five cases were analyzed. NRS was documented only in one case. In all, 787 patients experienced no pain or mild pain (no pain, n = 242; mild pain, n = 545) and 168 patients severe pain or worse (severe pain, n = 155; intolerable pain, n = 13). In the severe pain group, 138 were treated with opioid analgesics or S-ketamine, while no pharmacological intervention was documented in 30 cases. Eight of the 138 cases with severe pain needed endotracheal intubation, whereas nine cases in the patients with mild or no pain needed endotracheal intubation; odds ratio (OR) 4.3 (p = 0.003).Conclusions: Effect was only documented in one patient after administering opioids in a patient with trauma population, where approximately 17 percent of patients experienced severe pain. Severe pain was correlated to male gender, respiratory intervention, opioid administration, and the diagnosis unspecified multiple injuries.

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Cost of Intravenous Analgesia for the Management of Acute Pain in the Emergency Department is Substantial in the United States

Journal of Health Economics and Outcomes Research ◽

10.36469/9793 ◽

2017 ◽

Vol 5 (1) ◽

pp. 1-15 ◽

Cited By ~ 1

Author(s):

Pamela P. Palmer ◽

Judith A. Walker ◽

Asad E. Patanwala ◽

Carin A. Hagberg ◽

John A. House

Keyword(s):

Emergency Department ◽

Acute Pain ◽

Severe Pain ◽

The United States ◽

Rapid Onset ◽

Opioid Use ◽

Nursing Time ◽

Opioid Administration ◽

Intravenous Analgesia ◽

Set Up

Background: Pain is a leading cause of admission to the emergency department (ED) and moderate-to-severe acute pain in medically supervised settings is often treated with intravenous (IV) opioids. With novel noninvasive analgesic products in development for this indication, it is important to assess the costs associated with IV administration of opioids. Materials and Methods: A retrospective observational study of data derived from the Premier database was conducted. All ED encounters of adult patients treated with IV opioids during a 2-year time period, who were charged for at least one IV opioid administration in the ED were included. Hospital reported costs were used to estimate the costs to administer IV opioids. Results: Over a 24 month-period, 7.3 million encounters, which included the administration of IV opioids took place in 614 US EDs. The mean cost per encounter of IV administration of an initial dose of the three most frequently prescribed opioids were: morphine $145, hydromorphone $146, and fentanyl $147. The main driver of the total costs is the cost of nursing time and equipment cost to set up and maintain an IV infusion ($140 ± 60). Adding a second dose of opioid, brings the average costs to $151-$154. If costs associated with the management of opioid-related adverse events and IV-related complications are also added, the total costs can amount to $269-$273. Of these 7.3 million encounters, 4.3 million (58%) did not lead to hospital admission of the patient and, therefore, the patient may have only required an IV catheter for opioid administration. Conclusions: IV opioid use in the ED is indicated for moderate-to-severe pain but is associated with significant costs. In subjects who are discharged from the ED and may not have required an IV for reasons other than opioid administration, rapid-onset analgesics for moderate-to-severe pain that do not require IV administration could lead to direct cost reductions and improved care.

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At-a-glance - Concurrent monitoring of opioid prescribing practices and opioid-related deaths: the context in Nova Scotia, Canada

Health Promotion and Chronic Disease Prevention in Canada ◽

10.24095/hpcdp.38.9.05 ◽

2018 ◽

Vol 38 (9) ◽

pp. 334-338 ◽

Cited By ~ 1

Author(s):

Emily Schleihauf ◽

Kirstin Crabtree ◽

Carolyn Dohoo ◽

Sarah Fleming ◽

Heather McPeake ◽

...

Keyword(s):

Nova Scotia ◽

Public Health Surveillance ◽

Monitoring Program ◽

Population Level ◽

Medical Examiner ◽

Opioid Use ◽

Prescribing Practices ◽

Opioid Prescribing ◽

Prescription Monitoring ◽

Dispensing Data

Timely public health surveillance is required to understand trends in opioid use and harms. Here, opioid dispensing data from the Nova Scotia Prescription Monitoring Program are presented alongside fatality data from the Nova Scotia Medical Examiner Service. Concurrent monitoring of trends in these data sources is essential to detect population-level effects (whether intended or unintended) of interventions related to opioid prescribing.

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Current Opioid Prescribing Patterns after Microdirect Laryngoscopy

Annals of Otology Rhinology & Laryngology ◽

10.1177/0003489419877912 ◽

2019 ◽

Vol 129 (2) ◽

pp. 142-148 ◽

Cited By ~ 2

Author(s):

Molly N. Huston ◽

Rouya Kamizi ◽

Tanya K. Meyer ◽

Albert L. Merati ◽

John Paul Giliberto

Keyword(s):

The United States ◽

Opioid Abuse ◽

Prescribing Patterns ◽

Opioid Analgesia ◽

Opioid Use ◽

Prescribing Practices ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Opioid Prescription ◽

Opioid Prescribing

Background: The prevalence of opioid abuse has become epidemic in the United States. Microdirect laryngoscopy (MDL) is a common otolaryngological procedure, yet prescribing practices for opioids following this operation are not well characterized. Objective: To characterize current opioid-prescribing patterns among otolaryngologists performing MDL. Methods: A cross-sectional survey of otolaryngologists at a national laryngology meeting. Results: Fifty-eight of 205 physician registrants (response rate 28%) completed the survey. Fifty-nine percent of respondents were fellowship-trained in laryngology. Respondents performed an average of 13.3 MDLs per month. Thirty-four percent of surgeons prescribe opioids for over two-thirds of their MDLs, while only 7% of surgeons never prescribe opioids. Eighty-eight percent of surgeons prescribed a combination opioid and acetaminophen compound, hydrocodone being the most common opioid component. Many surgeons prescribe non-opioid analgesics as well, with 70% and 84% of surgeons recommending acetaminophen and ibuprofen after MDL respectively. When opioids were prescribed, patient preference, difficult exposure and history of opioid use were the most influential patient factors. Concerns of opioid abuse, the physician role in the opioid crisis, and literature about postoperative non-opioid analgesia were also underlying themes in influencing opioid prescription patterns after MDL. Conclusions: In this study, over 90% of practicing physicians surveyed are prescribing opioids after MDL, though many are also prescribing non-opioid analgesia as well. Further studies should be completed to investigate the needs of patients following MDL in order to allow physicians to selectively and appropriately prescribe opioid analgesia postoperatively.

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The relationship between patient factors and the refusal of analgesics in adult Emergency Department patients with extremity injuries, a case-control study

Scandinavian Journal of Pain ◽

10.1515/sjpain-2019-0077 ◽

2019 ◽

Vol 20 (1) ◽

pp. 87-94

Author(s):

Milan L. Ridderikhof ◽

Donica V. Lodder ◽

Susan Van Dieren ◽

Philipp Lirk ◽

Helma Goddijn ◽

...

Keyword(s):

Emergency Department ◽

Pain Score ◽

Pain Treatment ◽

Pain Medication ◽

Related Factors ◽

Analgesic Treatment ◽

Patient Beliefs ◽

Emergency Department Patients ◽

Extremity Injuries ◽

The Relationship

AbstractBackground and aimsPrevious studies have described the phenomenon of oligo-analgesia in Emergency Department patients with traumatic injuries, despite the high prevalence of pain among these patients. Besides aspects related to health care staff, patient related factors might also play a role in suboptimal pain treatment, however evidence is scarce. Therefore, the objective of the current study was to evaluate patient related factors in adult patients refusing offered analgesics during an Emergency Department presentation with extremity injuries.MethodsThis was a case control study in the Emergency Department of a level 1 Trauma Centre. Cases were defined as adult patients with an extremity injury who declined analgesia, when offered. They were matched to controls from the same population, who accepted analgesics, in a 1:2 ratio using gender as matching variable. Primary outcome was difference in NRS pain score. Secondary outcomes were the relationship between categorical severity of pain scores and refusal of analgesics, exploration of independent predictors of analgesia refusal utilizing multivariate logistic regression and the evaluation of eight beliefs among patients who refuse analgesics.ResultsBetween August 1st and 31st 2016, a total of 253 patients were eligible for inclusion of whom 55 declined analgesic treatment. They were included as cases and matched to 110 controls. Difference in median NRS pain score was significant between the groups: 5.0 (IQR 3.0–8.0) vs. 8.0 (IQR 6.0–9.0), respectively (p < 0.01). Nearly 20% of patients with severe pain declined analgesics, compared to 41% with moderate and 69% with mild pain (p < 0.01). The NRS pain score was the only independent predictor of refusal of analgesic treatment with a mean Odds Ratio of 0.67 (95%-CI 0.54–0.83). Most common patients’ beliefs were that pain medication should be used in extreme pain only, fear of decreasing the doctor’s ability to judge the injury and fear of addiction to analgesics.ConclusionsPain severity is the single independent predictor of refusal of analgesia, however the following patient beliefs are important as well: pain medication should be used in extreme pain only; fear of decreasing the doctor’s ability to judge the injury and the fear of becoming addicted to pain medication.ImplicationsIn case patients refuse offered analgesics, the health care provider should actively address patient beliefs that might exist and lead to suboptimal pain treatment.

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