1
|
Gottlieb M, Bernard K. Epidemiology of back pain visits and medication usage among United States emergency departments from 2016 to 2023. Am J Emerg Med 2024; 82:125-129. [PMID: 38905718 DOI: 10.1016/j.ajem.2024.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 06/04/2024] [Accepted: 06/11/2024] [Indexed: 06/23/2024] Open
Abstract
INTRODUCTION Low back pain is a common reason for presentation to the Emergency Department (ED). However, there are limited large-scale, recent data on the epidemiology, disposition, and medication administration for this condition. The objective of this was to assess the incidence, admission rates, medication administrations, and discharge prescriptions among ED visits for low back pain in the United States. METHODS This was a cross-sectional study of ED presentations for low back pain from 1/1/2016 to 12/31/2023 using the Epic Cosmos database. All ED visits for adults with low back pain identified by ICD-10 codes were included. Outcomes included admission rates, distribution of opioid, benzodiazepine, (non-benzodiazepine) muscle relaxant, acetaminophen, NSAID, and corticosteroid medications administered in the ED, and distribution of opioid, benzodiazepine, muscle relaxant, and corticosteroid medications given upon discharge. Subgroup analyses were performed by specific medication. RESULTS Of 207,154,419 ED encounters, 12,241,240 (5.9%) were due to back pain with 1,957,299 of these (16.0%) admitted. The admission rate increased over time from 12.8% to 17.1%. The most common medication given in the ED was opioids (40.7%), followed by acetaminophen (37.8%), NSAIDs (22.6%), muscle relaxants (18.4%) benzodiazepines (12.8%), and corticosteroids (5.5%). The most common medications prescribed upon discharge were muscle relaxants (32.1%), followed by opioids (23.2%), corticosteroids (12.2%), and benzodiazepines (3.0%). CONCLUSION Low back pain represents a common reason for presentation to the ED, and admissions have been increasing over time. Opioids remain the most common ED medication, whereas muscle relaxants have arisen as the most common discharge prescription. These findings can help inform health policy decisions, resource allocation, and evidence-based interventions for medication administration.
Collapse
Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America.
| | - Kyle Bernard
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
| |
Collapse
|
2
|
Barrington G, Davis K, Aandahl Z, Hose BA, Arthur M, Tran V. Influences of Software Changes on Oxycodone Prescribing at an Australian Tertiary Emergency Department: A Retrospective Review. PHARMACY 2024; 12:44. [PMID: 38525724 PMCID: PMC10961781 DOI: 10.3390/pharmacy12020044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 02/19/2024] [Accepted: 02/28/2024] [Indexed: 03/26/2024] Open
Abstract
Opioid prescribing and dispensing from emergency departments is a noteworthy issue given widespread opioid misuse and diversion in many countries, contributing both physical and economic harm to the population. High patient numbers and the stochastic nature of acute emergency presentations to emergency departments (EDs) introduce challenges for prescribers who are considering opioid stewardship principles. This study investigated the effect of changes to electronic prescribing software on prescriptions with an auto-populated quantity of oxycodone immediate release (IR) from an Australian tertiary emergency department following the implementation of national recommendations for reduced pack sizes. A retrospective review of oxycodone IR prescriptions over two six-month periods between 2019 and 2021 was undertaken, either side of a software adjustment to reduce the default quantities of tablets prescribed from 20 to 10. Patient demographic details were collected, and prescriber years of practice calculated for inclusion in linear mixed effects regression modelling. A reduction in the median number of tablets prescribed per prescription following the software changes (13.5 to 10.0, p < 0.001) with little change in the underlying characteristics of the patient or prescriber populations was observed, as well as an 11.65% reduction in the total number of tablets prescribed. The prescriber's years of practice, patient age and patient sex were found to influence increased prescription sizes. Reduced quantity of oxycodone tablets prescribed was achieved by alteration of prescribing software prefill parameters, providing further evidence to support systems-based policy interventions to influence health care providers behaviour and to act as a forcing function for prescribers to consider opioid stewardship principles.
Collapse
Affiliation(s)
- Giles Barrington
- Royal Hobart Hospital, Tasmanian Health Service, Hobart 7000, Australia; (B.-A.H.); (M.A.); (V.T.)
| | | | - Zach Aandahl
- School of Natural Sciences, University of Tasmania, Hobart 7000, Australia;
| | - Brodie-Anne Hose
- Royal Hobart Hospital, Tasmanian Health Service, Hobart 7000, Australia; (B.-A.H.); (M.A.); (V.T.)
| | - Mitchell Arthur
- Royal Hobart Hospital, Tasmanian Health Service, Hobart 7000, Australia; (B.-A.H.); (M.A.); (V.T.)
| | - Viet Tran
- Royal Hobart Hospital, Tasmanian Health Service, Hobart 7000, Australia; (B.-A.H.); (M.A.); (V.T.)
- School of Medicine, University of Tasmania, Hobart 7000, Australia
- Menzies Institute for Medical Research, University of Tasmania, Hobart 7000, Australia
| |
Collapse
|
3
|
Hoppe JA, Ledbetter C, Tolle H, Heard K. Implementation of Electronic Health Record Integration and Clinical Decision Support to Improve Emergency Department Prescription Drug Monitoring Program Use. Ann Emerg Med 2024; 83:3-13. [PMID: 37632496 DOI: 10.1016/j.annemergmed.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/30/2023] [Accepted: 07/06/2023] [Indexed: 08/28/2023]
Abstract
STUDY OBJECTIVE(S) To evaluate the implementation of 3 electronic health record (EHR)-based interventions to increase prescription drug monitoring program (PDMP) use in the emergency department (ED): EHR-PDMP integration, addition of a PDMP risk score, and addition of EHR-based clinical decision support alert to review the PDMP when prescribing an opioid. METHODS Three intervention stages were implemented using a prospective stepped-wedge design at 5 university-affiliated EDs split into 3 practice groups. The PDMP use and prescribing rates during the 3 stages were compared with baseline before EHR integration and a sustainability stage where the clinical decision support alert was removed, but EHR integration and risk score remained. Generalized linear mixed model with logit link function and a random intercept for clinicians was analyzed. RESULTS The ED provider PDMP review before opioid prescribing was low in all stages. The highest review rate occurred during interruptive clinical decision support alerts, 23.8% (interquartile range 10.6 to 37.5). Overall, opioid prescribing declined, and PDMP review was not associated with a decrease in opioid prescribing. PDMP review was associated with a reduction in the probability of prescribing an opioid as the number of prior opioid prescriptions increased (odds ratio: 0.92 [95% confidence interval: 0.91 to 0.94] for every additional prescription). CONCLUSION The EHR-PDMP integration did not increase PDMP use in the ED, but a PDMP risk score and a clinical decision support alert were associated with modest increases in the probability of PDMP review. When the PDMP is reviewed, ED clinicians are less likely to prescribe opioids to patients with a high number of prior opioid prescriptions.
Collapse
Affiliation(s)
- Jason A Hoppe
- Department of Emergency Medicine, University of Colorado, Aurora, CO.
| | - Caroline Ledbetter
- Center for Innovative Design and Analysis, the Colorado School of Public Health, Aurora, CO
| | - Heather Tolle
- Department of Emergency Medicine, University of Colorado, Aurora, CO
| | - Kennon Heard
- Department of Emergency Medicine, University of Colorado, Aurora, CO
| |
Collapse
|
4
|
Horn ME, Simon CB, Lee HJ, Eucker SA. Associations Between Management Pathway and Opioid Prescriptions for Patients Entering the Emergency Department With Neck and Back Pain. Mayo Clin Proc Innov Qual Outcomes 2023; 7:490-498. [PMID: 37842687 PMCID: PMC10568062 DOI: 10.1016/j.mayocpiqo.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Abstract
Objective To determine associations between post-emergency department (ED) management pathways and downstream opioid prescriptions in patients seeking care for incident neck and/or back pain. Patients and Methods We identified patients seeking first-time ED care for neck and/or back pain from January 1, 2013, through November 6, 2017. We reported demographic characteristics and opioid prescriptions across management pathways using descriptive statistics and assessed the relative risk of any opioid prescription 12 months post-ED visit among 5 different post-ED management pathways using Poisson regression adjusted for patient demographic characteristics. Results Within 12 months after the index ED visit, 58.0% (n=10,949) were prescribed an opioid, with most patients prescribed an opioid within the first week (average daily morphine milligram equivalents of 6.8 mg (SD 9.6 mg). The morphine milligram equivalents decreased to 0.7 mg (SD 8.2 mg) by week 4 and remained consistently less than 1 mg between week 4 and 12 months. Compared with the ED to primary care provider pathway, the relative risk of opioid prescription between 7 days and 12 months after the index ED visit was similar for the ED to physical therapy pathway, higher for both the ED to hospital admission or repeat ED visit pathway (30% increase; relative risk (RR), 1.3; 95% CI, 1.17-1.44) and the ED to specialist pathway (19% increase; RR, 1.19; 95% CI, 1.07-1.33), and lower in the ED with no follow-up visits pathway (41% decrease; RR, 0.59; 95% CI, 0.54-0.65). Conclusion In general, more conservative care was associated with lower opioid prescription rates, and escalated care was associated with higher opioid prescription rates.
Collapse
Affiliation(s)
- Maggie E. Horn
- Department of Orthopaedic Surgery, Division of Physical Therapy, Duke University, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
| | - Corey B. Simon
- Department of Orthopaedic Surgery, Division of Physical Therapy, Duke University, Durham, NC
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | | |
Collapse
|
5
|
Eucker SA, Glass O, Staton CA, Knisely MR, O'Regan A, De Larco C, Mill M, Dixon A, TumSuden O, Walker E, Dalton JC, Limkakeng A, Maxwell AMW, Gordee A, Kuchibhatla M, Chow S. Acupuncture for acute musculoskeletal pain management in the emergency department and continuity clinic: a protocol for an adaptive pragmatic randomised controlled trial. BMJ Open 2022; 12:e061661. [PMID: 36153034 PMCID: PMC9511597 DOI: 10.1136/bmjopen-2022-061661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 09/05/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Chronic musculoskeletal pain causes a significant burden on health and quality of life and may result from inadequate treatment of acute musculoskeletal pain. The emergency department (ED) represents a novel setting in which to test non-pharmacological interventions early in the pain trajectory to prevent the transition from acute to chronic pain. Acupuncture is increasingly recognised as a safe, affordable and effective treatment for pain and anxiety in the clinic setting, but it has yet to be established as a primary treatment option in the ED. METHODS AND ANALYSIS This pragmatic clinical trial uses a two-stage adaptive randomised design to determine the feasibility, acceptability and effectiveness of acupuncture initiated in the ED and continued in outpatient clinic for treating acute musculoskeletal pain. The objective of the first (treatment selection) stage is to determine the more effective style of ED-based acupuncture, auricular acupuncture or peripheral acupuncture, as compared with no acupuncture. All arms will receive usual care at the discretion of the ED provider blinded to treatment arm. The objective of the second (effectiveness confirmation) stage is to confirm the impact of the selected acupuncture arm on pain reduction. An interim analysis is planned at the end of stage 1 based on probability of being the best treatment, after which adaptations will be considered including dropping the less effective arm, sample size re-estimation and unequal treatment allocation ratio (eg, 1:2) for stage 2. Acupuncture treatments will be delivered by licensed acupuncturists in the ED and twice weekly for 1 month afterward in an outpatient clinic. ETHICS AND DISSEMINATION This study has been reviewed and approved by the Duke University Health System Institutional Review Board. Informed consent will be obtained from all participants. Results will be disseminated through peer-review publications and public and conference presentations. TRIAL REGISTRATION NUMBER NCT04290741.
Collapse
Affiliation(s)
- Stephanie A Eucker
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Oliver Glass
- Department of Medicine, Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Catherine A Staton
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Global Health Institute, Durham, North Carolina, USA
| | | | - Amy O'Regan
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Christi De Larco
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michelle Mill
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Austin Dixon
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Olivia TumSuden
- UNC Adams School of Dentistry, Chapel Hill, North Carolina, USA
| | - Erica Walker
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Juliet C Dalton
- Duke Office of Clinical Research, Duke University, Durham, North Carolina, USA
| | - Alexander Limkakeng
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Alex Gordee
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Maggie Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
- Center for Aging, Duke University, Durham, North Carolina, USA
| | - Sheinchung Chow
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| |
Collapse
|
6
|
Kawchuk GN, Aaskov J, Mohler M, Lowes J, Kruhlak M, Couperthwaite S, Yang EH, Villa-Roel C, Rowe BH. A prospective study of patients with low back pain attending a Canadian emergency department: Why they came and what happened? PLoS One 2022; 17:e0268123. [PMID: 35536825 PMCID: PMC9089857 DOI: 10.1371/journal.pone.0268123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 04/22/2022] [Indexed: 11/30/2022] Open
Abstract
Low back pain is a common presentation to emergency departments, but the reasons why people choose to attend the emergency department have not been explored. We aimed to fill this gap with this study to understand why persons with low back pain choose to attend the emergency department. Between July 4, 2017 and October 1, 2018, consecutive patients with a complaint of low back pain presenting to the University of Alberta Hospital emergency department were screened. Those enrolled completed a 13-item questionnaire to assess reasons and expectations related to their presentation. Demographics, acuity and disposition were obtained electronically. Factors associated with admission were examined in a logistic regression model. After screening 812 patients, 209 participants met the study criteria. The most common Canadian Triage and Acuity Scale score was 3 (73.2%). Overall, 37 (17.7%) received at least one consultation, 89.0% of participants were discharged home, 9.6% were admitted and 1.4% were transferred. Participants had a median pain intensity of 8/10 and a median daily functioning of 3/10. When asked, 64.6% attended for pain control while 44.5% stated ease of access. Most participants expected to obtain pain medication (67%) and advice (56%). Few attended because of cost savings (3.8%). After adjustment, only advanced age and ambulance arrival were significantly associated with admission. In conclusion, most low back pain patients came to the emergency department for pain control yet few were admitted and the majority did not receive a consultation. Timely alternatives for management of low back pain in the emergency department appear needed, yet are lacking.
Collapse
Affiliation(s)
- Gregory N. Kawchuk
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
- * E-mail:
| | - Jacob Aaskov
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Matthew Mohler
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Justin Lowes
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Maureen Kruhlak
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Stephanie Couperthwaite
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Esther H. Yang
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Cristina Villa-Roel
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Brian H. Rowe
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
- School of Public Health, University of Alberta, Edmonton, Canada
| |
Collapse
|
7
|
Megalla M, Ogedegbe C, Sanders AM, Cox N, DiSanto T, Johnson H, Kelly M, Koerner JD. Factors Associated With Repeat Emergency Department Visits for Low Back Pain. Cureus 2022; 14:e21906. [PMID: 35265428 PMCID: PMC8898564 DOI: 10.7759/cureus.21906] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2022] [Indexed: 12/19/2022] Open
Abstract
Background Low back pain represents 2-3% of Emergency Department (ED) visits. In this study, we aimed to identify patient and treatment-related variables that contributed to repeat visits to the ED for low back pain within a 12-month period. Methodology We conducted a retrospective review of adult patients presenting to the ED of one hospital over a two-year period with the primary diagnosis of low back pain. The primary outcome included return to the ED within 12 months with the same complaint, and the secondary outcome included return to the ED within 30 days or six months. Results A total of 793 patients met the inclusion criteria. The rate of return to the ED with the same complaint within 30 days, six months, and 12 months of the first visit was 7%, 11%, and 14%, respectively. Patients who received opioids at discharge were more likely to return within 12 months (68% vs. 55%; p = 0.0075) and six months (68% vs. 56%; p = 0.0184) compared to those who did not receive opioids at discharge. Undergoing an X-ray decreased the odds of a 30-day return visit by 70% (p = 0.0067), and by 59% within 12 months (p = 0.0032). Receiving opioids at discharge also doubled the odds of return within 12 months (odds ratio = 2.030, p = 0.0183), while receiving nonsteroidal anti-inflammatory drugs (NSAIDs) reduced the odds by 60% (p = 0.0028). Conclusions Patients who received opioids at discharge were more likely to have a return visit for low back pain within six and 12 months. Patients who underwent X-rays at the index visit and were prescribed NSAIDs at discharge were less likely to return to the ED for low back pain.
Collapse
Affiliation(s)
- Martinus Megalla
- Department of Orthopedic Surgery, Hackensack Meridian School of Medicine, Nutley, USA
| | - Chinwe Ogedegbe
- Department of Emergency Medicine, Hackensack University Medical Center, Hackensack, USA
| | - Angeline M Sanders
- Office of Clinical Research Administration, Hackensack University Medical Center, Hackensack, USA
| | - Nicole Cox
- Department of Emergency Medicine, Hackensack University Medical Center, Hackensack, USA
| | - Thomas DiSanto
- Department of Orthopedic Surgery, Hackensack Meridian School of Medicine, Nutley, USA
| | - Haley Johnson
- Department of Orthopedic Surgery, Hackensack Meridian School of Medicine, Nutley, USA
| | - Michael Kelly
- Department of Orthopedic Surgery, Hackensack University Medical Center, Hackensack, USA
| | - John D Koerner
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Paramus, USA
- Department of Orthopedic Surgery, Hackensack University Medical Center, Hackensack, USA
| |
Collapse
|
8
|
Lau T, Hayward J, Vatanpour S, Innes G. Sex-related differences in opioid administration in the emergency department: a population-based study. Emerg Med J 2021; 38:467-473. [PMID: 33853938 DOI: 10.1136/emermed-2020-210215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 02/16/2021] [Accepted: 03/24/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Sex differences in pain experience and expression may influence ED pain management. Our objective was to evaluate the effect of sex on ED opioid administration. METHODS We conducted a multicentre population-based observational cohort study using administrative data from Calgary's four EDs between 2017 and 2018. Eligible patients had a presenting complaint belonging to one of nine pain categories or an arrival pain score >3. We performed multivariable analyses to identify predictors of opioid administration and stratified analyses by age, pain severity and pain category. RESULTS We studied 119 510 patients (mean age 47.4 years; 55.4% female). Opioid administration rates were similar for men and women. After adjusting for age, hospital site, pain category, ED length of stay and pain severity, male sex was not a predictor of opioid treatment (adjusted OR (aOR)=0.93; 95% CI 0.85 to 1.02). However, men were more likely to receive opioids in the categories of trauma (aOR=1.58, 95% CI 1.40 to 1.78), flank pain (aOR=1.24, 95% CI 1.11 to 1.38), headache (aOR=1.18, 95% CI 1.03 to 1.34) and abdominal pain (aOR=1.11, 95% CI 1.08 to 1.18). Pain category appears to be a strong determinant of opioid administration, especially back pain (aOR=6.56, 95% CI 5.99 to 7.19) and flank pain (aOR=6.04, 95% CI 5.48 to 6.65). There was significant variability in opioid provision by ED site (aOR 0.76 to 1.24). CONCLUSIONS This population-based study demonstrated high variability in opioid use across different settings. Overall, men and women had similar likelihood of receiving opioids; however men with trauma, flank pain, headache and abdominal pain were much more likely to receive opioids. ED physicians should self-examine their analgesic practices with respect to possible sex biases, and departments should introduce evidence-based, indication-specific analgesic protocols to reduce practice variability and optimise opioid analgesia.
Collapse
Affiliation(s)
- Torey Lau
- Family Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Jake Hayward
- Emergency Medicine, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
| | - Shabnam Vatanpour
- Emergency Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Grant Innes
- Emergency Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| |
Collapse
|
9
|
McCann-Pineo M, Ruskin J, Rasul R, Vortsman E, Bevilacqua K, Corley SS, Schwartz RM. Predictors of emergency department opioid administration and prescribing: A machine learning approach. Am J Emerg Med 2020; 46:217-224. [PMID: 33071093 DOI: 10.1016/j.ajem.2020.07.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/08/2020] [Accepted: 07/10/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The opioid epidemic has altered normative clinical perceptions on addressing both acute and chronic pain, particularly within the Emergency Department (ED) setting, where providers are now confronted with balancing pain management and potential abuse. This study aims to examine patient sociodemographic and ED clinical characteristics to comprehensively determine predictors of opioid administration during an ED visit (ED-RX) and prescribing upon discharge (DC-RX). METHODS ED visit data of patients ≥18 years old from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2014 to 2017 were used. Opioid prescriptions were determined utilizing Lexicon narcotic drug classifications. Visit characteristics studied included sociodemographic variables, and ED clinical variables, such as chief complaint, and discharge diagnosis. Machine learning methods were used to determine predictors of ED-RX and DC-RX and weighted logistic regressions were performed using selected predictors. RESULTS Of the 44,227 ED visits identified, patients tended to be female (57.4%), and White (74.2%) with an average age of 46.4 years (SE = 0.3). Weighted proportions of ED-RX and DC-RX were 23.2% and 18.9%, respectively. The strongest predictors of ED-RX were CT scan ordered (OR = 2.18, 95% CI = 1.84-2.58), abdominal pain (OR = 1.93, 95% CI:1.59-2.34) and back pain (OR = 1.81, 95% CI:1.45-2.27). Tooth pain (OR = 6.94, 95% CI = 4.40-10.94) and fracture injury diagnoses (OR = 3.76, 95% CI = 2.72-5.19) were the strongest predictors of DC-RX. CONCLUSIONS These findings demonstrate the utility of machine learning for understanding clinical predictors of opioid administration and prescribing in the ED, and its potential in informing standardized prescribing recommendations and guidelines.
Collapse
Affiliation(s)
- Molly McCann-Pineo
- Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, 175 Community Drive, 2nd floor, Great Neck, NY 11021, USA; Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, 175 Community Drive, 2nd floor, Great Neck, NY 11021, USA; The Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY 11030, USA; Joint Center for Disaster Health, Trauma and Resilience at Mount Sinai, Stony Brook University and Northwell Health, New York, USA.
| | - Julia Ruskin
- Department of Computer Science, Princeton University, 35 Olden St, Princeton, NJ 08540, USA.
| | - Rehana Rasul
- Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, 175 Community Drive, 2nd floor, Great Neck, NY 11021, USA; Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, 175 Community Drive, 2nd floor, Great Neck, NY 11021, USA; The Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY 11030, USA; Joint Center for Disaster Health, Trauma and Resilience at Mount Sinai, Stony Brook University and Northwell Health, New York, USA.
| | - Eugene Vortsman
- Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, 175 Community Drive, 2nd floor, Great Neck, NY 11021, USA; Department of Emergency Medicine, Long Island Jewish Medical Center, Northwell Health, 270-05 76th Ave, Queens, NY 11040, USA,.
| | - Kristin Bevilacqua
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, USA.
| | - Samantha S Corley
- Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, 175 Community Drive, 2nd floor, Great Neck, NY 11021, USA; The Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY 11030, USA; Joint Center for Disaster Health, Trauma and Resilience at Mount Sinai, Stony Brook University and Northwell Health, New York, USA.
| | - Rebecca M Schwartz
- Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, 175 Community Drive, 2nd floor, Great Neck, NY 11021, USA; Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, 175 Community Drive, 2nd floor, Great Neck, NY 11021, USA; The Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY 11030, USA; Joint Center for Disaster Health, Trauma and Resilience at Mount Sinai, Stony Brook University and Northwell Health, New York, USA; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra Blvd, Hempstead, NY 11549, USA; Institute for Translational Epidemiology and Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue, Room 2-70A, New York, NY 10029, USA.
| |
Collapse
|
10
|
Carnide N, Hogg-Johnson S, Côté P, Koehoorn M, Furlan AD. Factors associated with early opioid dispensing compared with NSAID and muscle relaxant dispensing after a work-related low back injury. Occup Environ Med 2020; 77:637-647. [PMID: 32636331 DOI: 10.1136/oemed-2019-106380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/31/2020] [Accepted: 04/22/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES The objective of this historical cohort study was to determine the claimant and prescriber factors associated with receiving opioids at first postinjury dispense compared with non-steroidal anti-inflammatory drugs (NSAIDs) and skeletal muscle relaxants (SMRs) in a sample of workers' compensation claimants with low back pain (LBP) claims between 1998 and 2009 in British Columbia, Canada. METHODS Administrative workers' compensation, prescription and healthcare data were linked. The association between claimant factors (sociodemographics, occupation, diagnosis, comorbidities, pre-injury prescriptions and healthcare) and prescriber factors (sex, birth year, specialty) with drug class(es) at first dispense (opioids vs NSAIDs/SMRs) was examined with multilevel multinomial logistic regression. RESULTS Increasing days supplied with opioids in the previous year was associated with increased odds of receiving opioids only (1-14 days OR 1.62, 95% CI 1.51 to 1.75; ≥15 days OR 5.12, 95% CI 4.65 to 5.64) and opioids with NSAIDs/SMRs (1-14 days OR 1.49, 95% CI 1.39 to 1.60; ≥15 days OR 2.82, 95% CI 2.56 to 3.12). Other significant claimant factors included: pre-injury dispenses for NSAIDs, SMRs, antidepressants, anticonvulsants and sedative-hypnotics/anxiolytics; International Statistical Classification of Diseases and Related Health Problems, 9th Revision diagnosis; various pre-existing comorbidities; prior physician visits and hospitalisations; and year of injury, age, sex, health authority and occupation. Prescribers accounted for 25%-36% of the variability in the drug class(es) received, but prescriber sex, specialty and birth year did not explain observed between-prescriber variation. CONCLUSIONS During this period in the opioid crisis, early postinjury dispensing was multifactorial, with several claimant factors associated with receiving opioids at first prescription. Prescriber variation in drug class choice appears particularly important, but was not explained by basic prescriber characteristics.
Collapse
Affiliation(s)
- Nancy Carnide
- Institute for Work and Health, Toronto, Ontario, Canada
| | - Sheilah Hogg-Johnson
- Institute for Work and Health, Toronto, Ontario, Canada.,Research & Innovation, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Pierre Côté
- Research & Innovation, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada.,Centre for Disability Prevention and Rehabilitation, Ontario Tech University, Oshawa, Ontario, Canada
| | - Mieke Koehoorn
- Institute for Work and Health, Toronto, Ontario, Canada.,School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrea D Furlan
- Institute for Work and Health, Toronto, Ontario, Canada.,KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
11
|
Abstract
Opioid use disorder and opioid misuse continue to increase rapidly in prevalence in North America. Nurses play a critical role in managing pain in patients who are at risk for opioid use disorder. The interplay of pain and opioid use disorder provides nurses with an opportunity to address urgent needs while treating patients across the continuum of care. This article reviews strategies for assessing risk for opioid use disorder while treating patients with pain. Implementing these approaches into daily nursing practice may improve patient care and help reduce the incidence of opioid use disorder.
Collapse
Affiliation(s)
- Barbara St Marie
- Barbara St. Marie is Assistant Professor, College of Nursing, University of Iowa, 50 Newton Road, Iowa City, IA
| |
Collapse
|
12
|
Opioid prescription practices for patients discharged from the emergency department with acute musculoskeletal fractures. CAN J EMERG MED 2020; 22:486-493. [PMID: 32436484 DOI: 10.1017/cem.2020.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Opioid related mortality rate has increased 200% over the past decade. Studies show variable emergency department (ED) opioid prescription practices and a correlation with increased long-term use. ED physicians may be contributing to this problem. Our objective was to analyze ED opioid prescription practices for patients with acute fractures. METHODS We conducted a review of ED patients seen at two campuses of a tertiary care hospital. We evaluated a consecutive sample of patients with acute fractures (January 2016-April 2016) seen by ED physicians. Patients admitted or discharged by consultant services were excluded. The primary outcome was the proportion of patients discharged with an opioid prescription. Data were collected using screening lists, electronic records, and interobserver agreement. We calculated simple descriptive statistics and a multivariable analysis. RESULTS We enrolled 816 patients, including 441 females (54.0%). Most common fracture was wrist/hand (35.2%). 260 patients (31.8%) were discharged with an opioid; hydromorphone (N = 115, range 1-120 mg) was most common. 35 patients (4.3%) had pain related ED visits <1 month after discharge. Fractures of the lumbar spine (OR 10.78 [95% CI: 3.15-36.90]) and rib(s)/sternum/thoracic spine (OR 5.46 [95% CI: 2.88-10.35)] had a significantly higher likelihood of opioid prescriptions. CONCLUSIONS The majority of patients presenting to the ED with acute fractures were not discharged with an opioid. Hydromorphone was the most common opioid prescribed, with large variations in total dosage. Overall, there were few return to ED visits. We recommend standardization of ED opioid prescribing, with attention to limiting total dosage.
Collapse
|
13
|
Kettler E, Brennan J, Coyne CJ. The effects of a morphine shortage on emergency department pain control. Am J Emerg Med 2020; 43:229-234. [PMID: 32192896 DOI: 10.1016/j.ajem.2020.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 03/05/2020] [Accepted: 03/08/2020] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE In 2018, due to a national morphine shortage, our two study emergency departments (EDs) were unable to administer intravenous (IV) morphine for over six months. We evaluated the effects of this shortage on analgesia and patient disposition. METHODS This was a retrospective study in two academic EDs. Our control period (with morphine) was 4/1/17-6/30/17 and our study period (without morphine) was 4/1/18-6/30/18. We included all adult patients with a chief complaint of pain, initial pain score ≥4, and ≥2 recorded pain scores. The primary outcome was delta pain score. Secondary outcomes included final pain score, proportion of ED visits with opioids vs. non-opioids administered, and ED disposition. RESULTS We identified 6296 patients during our control period and 5816 during our study period. There was no significant difference in mean final pain score (study 4.45, control 4.44, p = 0.802), delta pain score (study -3.30, control -3.32, p = 0.556), nor admission rates (study 18.8%, control 17.8%, p = 0.131). We saw a decrease in opioid use (study 47.4%, control 60.0%, p < 0.01) and an increased use of non-opioid analgesics (study 27.3%, control 18.44%, p < 0.01). CONCLUSIONS Removing IV morphine in the ED, without a compensatory rise in alternative opioids, does not appear to significantly impact analgesia or disposition. These data favor a more limited opioid use strategy in the ED.
Collapse
Affiliation(s)
- Ellen Kettler
- University of California, San Diego School of Medicine, La Jolla, CA, USA; Department of Emergency Medicine, 200 W. Arbor Dr. #8676 San Diego, CA 92103, USA.
| | - Jesse Brennan
- University of California, San Diego School of Medicine, La Jolla, CA, USA; Department of Emergency Medicine, 200 W. Arbor Dr. #8676 San Diego, CA 92103, USA.
| | - Christopher J Coyne
- University of California, San Diego School of Medicine, La Jolla, CA, USA; Department of Emergency Medicine, 200 W. Arbor Dr. #8676 San Diego, CA 92103, USA.
| |
Collapse
|
14
|
Smith BC, Vigotsky AD, Apkarian AV, Schnitzer TJ. Temporal Factors Associated With Opioid Prescriptions for Patients With Pain Conditions in an Urban Emergency Department. JAMA Netw Open 2020; 3:e200802. [PMID: 32211867 PMCID: PMC7097712 DOI: 10.1001/jamanetworkopen.2020.0802] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
IMPORTANCE Opioid prescriptions for treatment of pain in emergency departments (EDs) are associated with long-term opioid use. The temporal pattern of opioid prescribing in the context of the opioid epidemic remains unknown. OBJECTIVE To examine the temporal pattern of opioid prescribing within an ED for varying pain conditions between 2009 and 2018. DESIGN, SETTING, AND PARTICIPANTS A population-based, cross-sectional study was conducted at the ED of an urban academic medical center. All patients treated within that ED between January 1, 2009, and December 31, 2018, were included. MAIN OUTCOMES AND MEASURES The proportion of patients prescribed an opioid for treatment of pain in the ED temporally by condition, condition type, patient demographics, and physician prescriber. RESULTS Between 2009 and 2018, 556 176 patient encounters took place in the ED, with 70 218 unique opioid prescriptions ordered. A total of 316 632 patients (55.9%) were female, 45 070 (42.6%) were of white race, and 43 412 (40.6%) were privately insured; the median age group was 41 to 45 years. Yearly opioid prescriptions decreased by 66.3% (from 16.3 to 5.5 opioids per 100 encounters) between 2013 and 2018, with a yearly adjusted odds ratio (aOR) of 0.808 (95% CI, 0.802-0.814) compared with the prior year. In patients with musculoskeletal pain (back, joint, limb, and neck pain), opioid prescribing decreased by 71.1% (from 36.7 to 10.6 opioids per 100 encounters between 2013 and 2018; aOR, 0.758; 95% CI, 0.744-0.773). In patients with musculoskeletal trauma (fracture, sprain, contusion, and injury), opioid prescribing decreased by 58.0% (from 34.2 to 14.8 opioids per 100 encounters; aOR, 0.811; 95% CI, 0.797-0.824). In patients with nonmusculoskeletal pain (abdominal pain, kidney stone, respiratory distress, and pharyngitis) opioid prescribing decreased by 53.7% (from 20.1 to 9.3 opioids per 100 encounters; aOR, 0.850; 95% CI, 0.834-0.868). Between 2009 and 2018, patients who were black (aOR, 0.760; 95% CI, 0.741-0.779) and those who were Asian (aOR, 0.714; 95% CI, 0.665-0.764) had the lowest odds of receiving an opioid compared with other racial/ethnic groups. CONCLUSIONS AND RELEVANCE There was a substantial temporal decrease in the number of opioid prescriptions within this ED during the study period. This decrease was associated with substantial relative reductions in opioid prescribing for treatment of musculoskeletal pain compared with fractures and kidney stones.
Collapse
Affiliation(s)
- Ben C. Smith
- Medical Student, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Andrew D. Vigotsky
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois
- Department of Statistics, Northwestern University, Evanston, Illinois
| | - A. Vania Apkarian
- Center for Translational Pain Research, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Thomas J. Schnitzer
- Anesthesiology and Medicine (Rheumatology), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| |
Collapse
|
15
|
Corwell BN, Davis NL. The Emergent Evaluation and Treatment of Neck and Back Pain. Emerg Med Clin North Am 2019; 38:167-191. [PMID: 31757249 DOI: 10.1016/j.emc.2019.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Neck and back pain are among the most common symptom-related complaints for visits to the emergency department (ED). They contribute to high levels of lost work days, disability, and health care use. The goal of ED assessment of patients with neck and back pain is to evaluate for potentially dangerous causes that could result in significant morbidity and mortality. This article discusses the efficient and effective evaluation, management, and treatment of patients with neck and back pain in the ED. Emphasis is placed on vertebral osteomyelitis, epidural abscess, acute transverse myelitis, epidural compression syndrome, spinal malignancy, and spinal stenosis.
Collapse
Affiliation(s)
- Brian N Corwell
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA; Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Natalie L Davis
- Department of Pediatrics, University of Maryland School of Medicine, 110 S. Paca Street, 8th Floor, Baltimore, MD 21201, USA
| |
Collapse
|
16
|
Leventhal EL, Nathanson LA, Landry AM. Variations in Opioid Prescribing Behavior by Physician Training. West J Emerg Med 2019; 20:428-432. [PMID: 31123541 PMCID: PMC6526879 DOI: 10.5811/westjem.2019.3.39311] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 03/01/2019] [Accepted: 03/11/2019] [Indexed: 11/11/2022] Open
Abstract
Introduction Opioid abuse has reached epidemic proportions in the United States. Patients often present to the emergency department (ED) with painful conditions seeking analgesic relief. While there is known variability in the prescribing behaviors of emergency physicians, it is unknown if there are differences in these behaviors based on training level or by resident specialty. Methods This is a retrospective chart review of ED visits from a single, tertiary-care academic hospital over a single academic year (2014-2015), examining the amount of opioid pain medication prescribed. We compared morphine milligram equivalents (MME) between provider specialty and level of training (emergency medicine [EM] attending physicians, EM residents in training, and non-EM residents in training). Results We reviewed 55,999 total ED visits, of which 4,431 (7.9%) resulted in discharge with a prescription opioid medication. Residents in a non-EM training program prescribed higher amounts of opioid medication (108 MME, interquartile ratio [IQR] 75-150) than EM attendings (90 MME, lQR 75-120), who prescribed more than residents in an EM training program (75 MME, IQR 60-113) (p<0.01). Conclusion In an ED setting, variability exists in prescribing patterns with non-EM residents prescribing larger amounts of opioids in the acute setting. EM attendings should closely monitor for both over- and under-prescribing of analgesic medications.
Collapse
Affiliation(s)
- Evan L Leventhal
- Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Larry A Nathanson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Alden M Landry
- Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| |
Collapse
|
17
|
Bonnie RJ, Schumacher MA, Clark JD, Kesselheim AS. Pain Management and Opioid Regulation: Continuing Public Health Challenges. Am J Public Health 2019; 109:31-34. [PMID: 32941766 DOI: 10.2105/ajph.2018.304881] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The still-growing US opioid epidemic lies at the intersection of two major public health challenges: reducing suffering from pain and containing the rising toll of harms associated with the use of opioids medications. Responding successfully to these challenges requires a substantial investment in surveillance and research on many fronts and a coordinated policy response by federal and state agencies and stakeholder organizations.A 2017 report of the National Academies of Sciences, Engineering and Medicine (NASEM) called for improved methods of measuring pain and the effects of alternative modalities of treatment as well as intensive surveillance of opioid-related harms; urged a long-term cultural transformation of how pain is perceived, assessed and treated; and outlined a comprehensive and balanced public health framework to guide Food and Drug Administration approval, monitoring, and review of opioids.We, authors of the NASEM report, use the articles published in this special section of AJPH as a platform for commenting on the public health burden of pain, the role of opioids in managing pain, global disparities in access to opioids for pain management, divergent approaches to opioid regulation, and the challenge of striking a reasonable balance between the needs of patients in pain and the prevention of opioid-related harms.
Collapse
Affiliation(s)
- Richard J Bonnie
- Richard J. Bonnie is with the Institute of Law, Psychiatry and Public Policy, University of Virginia, Charlottesville. Mark A. Schumacher is with the Department of Anesthesia and Perioperative Care, University of California, San Francisco. J. David Clark is with the Department of Anesthesiology, Stanford University, Stanford, CA. Aaron S. Kesselheim is with the Program on Regulation, Therapeutics, and Law, Harvard Medical School, Cambridge, MA, and the Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Mark A Schumacher
- Richard J. Bonnie is with the Institute of Law, Psychiatry and Public Policy, University of Virginia, Charlottesville. Mark A. Schumacher is with the Department of Anesthesia and Perioperative Care, University of California, San Francisco. J. David Clark is with the Department of Anesthesiology, Stanford University, Stanford, CA. Aaron S. Kesselheim is with the Program on Regulation, Therapeutics, and Law, Harvard Medical School, Cambridge, MA, and the Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - J David Clark
- Richard J. Bonnie is with the Institute of Law, Psychiatry and Public Policy, University of Virginia, Charlottesville. Mark A. Schumacher is with the Department of Anesthesia and Perioperative Care, University of California, San Francisco. J. David Clark is with the Department of Anesthesiology, Stanford University, Stanford, CA. Aaron S. Kesselheim is with the Program on Regulation, Therapeutics, and Law, Harvard Medical School, Cambridge, MA, and the Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Aaron S Kesselheim
- Richard J. Bonnie is with the Institute of Law, Psychiatry and Public Policy, University of Virginia, Charlottesville. Mark A. Schumacher is with the Department of Anesthesia and Perioperative Care, University of California, San Francisco. J. David Clark is with the Department of Anesthesiology, Stanford University, Stanford, CA. Aaron S. Kesselheim is with the Program on Regulation, Therapeutics, and Law, Harvard Medical School, Cambridge, MA, and the Department of Medicine, Brigham and Women's Hospital, Boston, MA
| |
Collapse
|
18
|
Hong Y, Geraci M, Turk MA, Love BL, McDermott SW. Opioid Prescription Patterns for Adults With Longstanding Disability and Inflammatory Conditions Compared to Other Users, Using a Nationally Representative Sample. Arch Phys Med Rehabil 2019; 100:86-94.e2. [DOI: 10.1016/j.apmr.2018.06.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 06/26/2018] [Accepted: 06/30/2018] [Indexed: 02/08/2023]
|
19
|
Ward MJ, Kc D, Jenkins CA, Liu D, Padaki A, Pines JM. Emergency department provider and facility variation in opioid prescriptions for discharged patients. Am J Emerg Med 2018; 37:851-858. [PMID: 30077493 DOI: 10.1016/j.ajem.2018.07.054] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/09/2018] [Accepted: 07/30/2018] [Indexed: 12/19/2022] Open
Abstract
STUDY OBJECTIVE To study the variation in opioid prescribing among emergency physicians and facilities for discharged adult ED patients. METHODS We conducted a retrospective analysis of ED visits from five U.S. hospitals between January and May 2014 using records from Data to Intelligence (D2i). We examined physician- and facility-level variation in opioid prescription rates for discharged ED patients. We calculated unadjusted opioid prescription rates at the physician and facility levels and used a multivariable mixed-effect logistic regression model to examine within-facility physician variation in opioid prescription adjusting for patient and situational factors including time of presentation, ED census, and physician workload. RESULTS In 47,304 visits across five EDs, median patient age was 40 years old (IQR 28,55), and 89% had some form of insurance. There were 17,098 (36%) ED discharges with at least one opioid prescription. The unadjusted facility-level opioid prescription rate ranged from 24%-46%. Among 253 ED physicians, the adjusted opioid prescription rate varied from 22%-76%. Increased physician workload is related to decreased odds of opioid prescription at ED discharge for the lowest (<3 patients) and moderate (6-9 patients) physician workload levels, while the association weakened with increasing levels of workload. CONCLUSION There was substantial physician and facility variation in opioid prescription for discharged adult ED patients. Emergency physicians were less likely to prescribe opioids when their workload was lower, and this effect diminished at high workload levels. Understanding situational and other factors that explain this variation is important given the rising U.S. opioid epidemic and the need for urgent intervention.
Collapse
Affiliation(s)
- Michael J Ward
- Department of Emergency Medicine, Vanderbilt University School of Medicine, United States of America.
| | - Diwas Kc
- Information Systems & Operations Management, Goizueta Business School, Emory University, United States of America
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University School of Medicine, United States of America
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University School of Medicine, United States of America
| | - Amit Padaki
- Department of Emergency Medicine, Christiana Care Health System, United States of America
| | - Jesse M Pines
- Department of Emergency Medicine, Department Health Policy & Management, George Washington University School of Medicine and Health Sciences, United States of America
| |
Collapse
|
20
|
Weeks WB, Goertz CM, Long CR, Meeker WC, Marchiori DM. Association Among Opioid Use, Treatment Preferences, and Perceptions of Physician Treatment Recommendations in Patients With Neck and Back Pain. J Manipulative Physiol Ther 2018; 41:175-180. [PMID: 29456094 DOI: 10.1016/j.jmpt.2017.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 12/21/2017] [Accepted: 12/23/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The purpose of this study was to explore the relationship between self-reported use of opioids by patients with neck and back pain and their demographics, pain characteristics, treatment preferences, and recollections of their physicians' opinions regarding treatment options. METHODS We analyzed 2017 Gallup Poll survey data from 1680 US adults who had substantial spine pain in the past year and used logistic regression to explore the aforementioned relationships. RESULTS Our multiple regression analysis indicated that adults with neck or back pain severe enough to have sought health care within the last year were more likely to have used opioids in the last year if they (in descending order of marginal impact) had pain that had lasted 1 year or less (adjusted odds ratio [OR] = 34.35, 90% confidence interval [CI] 17.56-74.32); concurrently used benzodiazepines (OR = 6.02, 90% CI 2.95-12.33); had Medicaid as an insurance source (OR = 3.29, 90% CI 1.40-7.48); indicated that they preferred to use pain medications prescribed by a doctor to treat physical pain (OR = 3.24, 90% CI 1.88-5.60); or were not college educated (OR = 1.83, 90% CI 1.05-3.25). Compared with patients aged 65 years and older, those aged 18 to 34 years were less likely to have used opioids in the past year (OR = 0.09, 90% CI 0.01-0.40, 0.50 for 95% CI). Respondents' perceptions of medical doctors' positive or negative opinions regarding a variety of neck and back pain treatment options were not significantly associated with opioid use. CONCLUSIONS Patients with neck and back pain who use opioids differ from those who do not use opioids in that they are more likely to have pain that is of shorter duration, to use benzodiazepines, to have Medicaid as an insurance source, and to prefer to use pain medications. Those characteristics should be considered when developing opioid use prevention strategies.
Collapse
Affiliation(s)
- William B Weeks
- Palmer College of Chiropractic, Davenport, Iowa; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire.
| | | | | | | | | |
Collapse
|