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Jones CMP, Lin CWC, Jamshidi M, Abdel Shaheed C, Maher CG, Harris IA, Patanwala AE, Dinh M, Mathieson S. Effectiveness of Opioid Analgesic Medicines Prescribed in or at Discharge From Emergency Departments for Musculoskeletal Pain : A Systematic Review and Meta-analysis. Ann Intern Med 2022; 175:1572-1581. [PMID: 36252245 DOI: 10.7326/m22-2162] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The comparative benefits and harms of opioids for musculoskeletal pain in the emergency department (ED) are uncertain. PURPOSE To evaluate the comparative effectiveness and harms of opioids for musculoskeletal pain in the ED setting. DATA SOURCES Electronic databases and registries from inception to 7 February 2022. STUDY SELECTION Randomized controlled trials of any opioid analgesic compared with placebo or a nonopioid analgesic administered or prescribed to adults in or on discharge from the ED. DATA EXTRACTION Pain and disability were rated on a scale of 0 to 100 and pooled using a random-effects model. Certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. DATA SYNTHESIS Forty-two articles were included (n = 6128). In the ED, opioids were statistically but not clinically more effective in reducing pain in the short term (about 2 hours) than placebo and paracetamol (acetaminophen) but were not clinically or statistically more effective than nonsteroidal anti-inflammatory drugs (NSAIDs) or local or systemic anesthetics. Opioids may carry higher risk for harms than placebo, paracetamol, or NSAIDs, although evidence is very uncertain. There was no evidence of difference in harms associated with local or systemic anesthetics. LIMITATIONS Low or very low GRADE ratings for some outcomes, unexplained heterogeneity, and little information on long-term outcomes. CONCLUSION The risk-benefit balance of opioids versus placebo, paracetamol, NSAIDs, and local or systemic anesthetics is uncertain. Opioids may have equivalent pain outcomes compared with NSAIDs, but evidence on comparisons of harms is very uncertain and heterogeneous. Although factors such as route of administration or dosage may explain some heterogeneity, more work is needed to identify which subgroups will have a more favorable benefit-risk balance for one analgesic over another. Longer-term pain management once dose thresholds are reached is also uncertain. PRIMARY FUNDING SOURCE None. (PROSPERO: CRD42021275293).
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Affiliation(s)
- Caitlin M P Jones
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Masoud Jamshidi
- Department of Sports Physiology, University of Tehran, Tehran, Iran (M.J.)
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Ian A Harris
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW Sydney, Sydney, New South Wales, Australia (I.A.H.)
| | - Asad E Patanwala
- Royal Prince Alfred Hospital, and School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia (A.E.P.)
| | - Michael Dinh
- Sydney Local Health District and The University of Sydney, Sydney, New South Wales, Australia (M.D.)
| | - Stephanie Mathieson
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
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Coombs DM, Maher CG, Collett M, Mathieson S, Abdel Shaheed C, Lin CWC, Machado GC. Continued opioid use following an emergency department presentation for low back pain. Emerg Med Australas 2022; 34:694-697. [PMID: 35441464 DOI: 10.1111/1742-6723.13979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 01/31/2022] [Accepted: 02/05/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the proportion of patients with low back pain who receive an opioid analgesic prescription on hospital discharge, the proportion using opioid analgesics 4 weeks after discharge, and to identify predictors of continued opioid analgesic use at 4 weeks after an ED presentation in opioid-naïve patients. METHODS An observational cohort study nested within a randomised controlled trial in four EDs in New South Wales, Australia. Participants were adults who presented to the ED with non-specific low back pain or low back pain with lower limb neurological signs and symptoms. Electronic medical records supplemented the patient-reported pain and use of opioid analgesics at 4-week follow up. RESULTS Of the 104 patients included, 33 (31.7%, 95% confidence interval [CI] 22.9-41.6) received an opioid analgesic prescription at hospital discharge and 38 (36.5%, 95% CI 27.3-46.6) reported taking an opioid analgesic for pain 4 weeks after the ED presentation. Among opioid-naïve patients (n = 85), older age (odds ratio [OR] 1.04, 95% CI 1.00-1.08, P = 0.031) was the only predictor for continued opioid analgesic use at 4 weeks post-ED presentation. CONCLUSION About one-third of patients who present to the ED with low back pain receive an opioid analgesic prescription on discharge and are taking an opioid analgesic 4 weeks later. These findings justify future research to identify strategies to reduce the risk of long-term opioid use in patients who present to the ED with low back pain.
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Affiliation(s)
- Danielle M Coombs
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia.,Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Physiotherapy Department, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia.,Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Melinda Collett
- Physiotherapy Department, Dubbo Health Service, Western New South Wales Local Health District, Sydney, New South Wales, Australia
| | - Stephanie Mathieson
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia.,Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia.,Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia.,Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Gustavo C Machado
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia.,Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Althagafi SM, Hughes JA. Identifying the relationship between patient-reported outcomes and treatment with opiates in the adult emergency department - A cross-sectional study. Int Emerg Nurs 2022; 62:101152. [PMID: 35245729 DOI: 10.1016/j.ienj.2022.101152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/09/2022] [Accepted: 01/31/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Suhair M Althagafi
- School of Nursing, Queensland University of Technology, Brisbane, Australia; College of Nursing, Umm AlQura University, Makkah, Saudi Arabia
| | - James A Hughes
- School of Nursing, Queensland University of Technology, Brisbane, Australia.
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Pouryahya P, Birkett W, McR Meyer AD, Louey S, Belhadfa M, Ferdousi S, Imperial K, Nguyen P, Wang A. Oxycodone prescribing in the emergency department during the opioid crisis. Emerg Med Australas 2020; 32:996-1000. [PMID: 32537895 DOI: 10.1111/1742-6723.13545] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 04/01/2020] [Accepted: 04/29/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Misuse of prescription opioids is a significant public health issue in Australia. There has been a rapid rise in prescription opioid use, with an associated increase in overdose and death. The over-prescribing of oral opioids, especially oxycodone, in the ED has been identified as a contributor to this problem overseas. It is unclear if similar practice occurs in the Australian ED. The primary aim of our study was to identify the incidence of oral oxycodone administration to patients within the ED. The secondary outcome was to identify the incidence of oxycodone prescribed to patients on discharge from the ED into the community. METHODS Our study was designed as an observational, retrospective data analysis of the incidence of oxycodone prescribed within the three EDs of a large Australian public health service. All immediate-release (IR) and slow-release (SR) oral oxycodone prescribed over a 4-year period (2015-2018) was included. RESULTS There were 890 557 presentations to the three EDs during the period, which resulted in 288 242 episodes of oxycodone administration within department, equivalent to 324 administrations per 1000 presentations. There were 39 381 prescriptions for oxycodone provided on discharge, resulting in an incidence of 44 prescriptions per 1000 discharged. The most frequently prescribed opioid medication in the ED was oxycodone IR 5 mg, 78.6% of discharge prescriptions generated provided a maximum quantity (20 for IR formulation or 28 for SR) of tablets allowable under the pharmaceutical benefits scheme. CONCLUSIONS There is a higher incidence of oxycodone prescribing in the Australian ED than previously recognised. An overuse of oxycodone may be contributing to adverse patient outcomes and a public health crisis. Hospitals should consider appropriate steps to reduce the incidence of opioid prescribing and the supply of these medications into the community.
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Affiliation(s)
- Pourya Pouryahya
- Emergency Department, Program of Emergency Medicine, Casey Hospital, Monash Health, Melbourne, Victoria, Australia.,Monash Emergency Research Collaborative, Program of Emergency Medicine, Monash Health, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - William Birkett
- Emergency Department, Program of Emergency Medicine, Casey Hospital, Monash Health, Melbourne, Victoria, Australia
| | - Alastair D McR Meyer
- Emergency Department, Program of Emergency Medicine, Casey Hospital, Monash Health, Melbourne, Victoria, Australia.,Monash Emergency Research Collaborative, Program of Emergency Medicine, Monash Health, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Stephen Louey
- Pharmacy Department, Casey Hospital, Monash Health, Melbourne, Victoria, Australia
| | - Miriam Belhadfa
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Sapphire Ferdousi
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Kimberly Imperial
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Phi Nguyen
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Amber Wang
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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Veal F, Thompson A, Halliday S, Boyles P, Orlikowski C, Huckerby E, Bereznicki L. Does prescribing of immediate release oxycodone by emergency medicine physicians result in persistence of Schedule 8 opioids following discharge? Emerg Med Australas 2019; 32:489-493. [PMID: 31837655 DOI: 10.1111/1742-6723.13442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/31/2019] [Accepted: 11/24/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To identify the prevalence of oxycodone immediate release (IR) prescribed during an ED admission and the persistence of Schedule 8 (S8) opioids following an ED admission. METHODS A retrospective cross-sectional audit was undertaken reviewing all admission at the ED of the Royal Hobart Hospital, Tasmania, between 1 August and 30 September 2016. The admissions lists for ED were cross matched with the narcotic registers for oxycodone IR (the most commonly supplied S8 in ED) to identify how many patients received IR oxycodone during their ED admissions. Determination of the persistence of opioid use in opioid naïve patients was then undertaken using the Tasmanian real time reporting database of all S8 opioid dispensed in Tasmania (DAPIS). RESULTS There were 8432 ED admissions for 7065 patients aged over 13 years. IR oxycodone was prescribed during 1049 of these admissions (12.4%). Of the patients who were not taking regularly prescribed S8 opioids prior to their ED admission (n = 853), 48 patients (5.6%) were taking S8 opioids at both 2 and 6 months following their ED admission. Thirty patients (2.8%) were approved for authorities for long-term opioids for non-cancer pain. CONCLUSION These findings suggest that prescribing of IR oxycodone within ED is lower than previous studies. Additionally, the progression to regular chronic opioid use following an ED admission where IR oxycodone was given was relatively low with 3.0% of opioid naïve patients being approved for indications related to chronic non-cancer pain in the following 6 months.
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Affiliation(s)
- Felicity Veal
- Unit for Medication Outcomes Research & Education (UMORE), Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Angus Thompson
- Unit for Medication Outcomes Research & Education (UMORE), Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Samuel Halliday
- Department of Health, Tasmanian Government, Hobart, Tasmania, Australia
| | - Peter Boyles
- Department of Health, Tasmanian Government, Hobart, Tasmania, Australia
| | | | - Emma Huckerby
- Emergency Department, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Luke Bereznicki
- Unit for Medication Outcomes Research & Education (UMORE), Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
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