Study: Emergency physicians prescribe opioids at lower rates than other doctors

Opioid prescriptions written by emergency department clinicians tend to have lower doses and a shorter supply duration than when such medications are prescribed in other medical settings, according to a new study.

An analysis of more than 5.2 million opioid prescriptions written between 2009 and 2015 comparing prescribing characteristics between ED and non-ED clinicians found those written by emergency physicians were more likely to follow guidelines issued by the Centers for Disease Control and Prevention last year.

Those recommendations, intended for primary-care physicians treating chronic pain, suggested opioids should be prescribed only after trying non-pharmacological treatment methods, and for clinicians to start with dosage levels that don't exceed 50 morphine milligram equivalents, or MME, a day.

The study, published in the Annals of Emergency Medicine, found opioid prescriptions written from the emergency department were 23% to 37% less likely to have a dosage higher than 50 MME compared with non-ED prescriptions, and were 33% to 54% less likely to be written for dosages that exceeded 90 MME.

Still, the CDC guidelines don't properly address what is an appropriate dosage level to give patients who are not accustomed to taking opioids, said study lead author Molly Moore Jeffery, scientific director of the division of emergency medicine research at the Mayo Clinic. The study focused on opioid prescriptions filled by patients described as "opioid naive," or those who had no opioid prescription filled at least six months prior to visiting the ED.

"The MME number that's in the CDC guidelines is actually meant for people who are using opioids chronically, and you build up a tolerance as you use them," Jeffery said. "So, 50 MME for somebody who's not currently taking opioids is just a huge dose, and it's very likely to be unsafe for almost anybody who receives it—I think (the study) should be eye-opening to a lot of physicians to see how common that is."

A wider variation in opioid prescribing was found when it came to the duration of the prescription. The study found emergency departments were 84% to 91% less likely to write opioid prescriptions that exceeded a seven-day supply than prescription written in non-ED settings.

Results varied among patients based on their insurance status. More than 19% of patients with commercial insurance who received an opioid prescription in non-ED settings got a supply that exceeded seven days compared to just 3% patients in an ED. Among disabled Medicare patients, more than 40% of prescriptions filled in non-emergency medicine settings exceeded a seven-day supply compared with less than 5% of those filled in an ED.

Jeffery said it was important to examine why emergency physicians were more likely to write lower-dose, shorter-duration opioid prescriptions than physicians in other medical settings. She theorized that emergency physicians may have more experience with addressing acute pain in a vast array of patients than other specialties given that the majority of cases at an ED have acute pain-related issues.

"My hypothesis is that (non-ED doctors) don't build up a sense of what's the appropriate dose and duration when seeing a patient with acute pain," Jeffrey said. "One of the ideas we may be able to take from emergency physicians is let's try to set out so that there is a default dose and duration for acute pain and make it easier for physicians to make the right decisions."

She said she hoped the study's findings would lay to rest perceptions that opioid prescribing habits within emergency medicine settings have contributed to the nation's opioid crisis, with more than 64,000 drug overdose deaths in 2016, according to recent government figures. Initial exposure to opioids through a prescription while in a healthcare setting has been associated with patients developing substance use disorder and addiction issues.

According to the CDC, while the opioid prescribing rate declined by 13% between 2012 and 2015, the rate of prescribing in 2015 was more than three times what it was in 1999.

Though prescribing rates are highest in the pain medicine, surgery and physical rehabilitation specialties, in terms of volume, primary-care providers account for half of all opioid pain relievers dispensed, according to the CDC.

But previous studies have pointed to lower prescribing rates among emergency medicine clinicians. A 2015 analysis of opioid prescribing within emergency departments published in the Annals of Emergency Medicine found that 17% of patients were given an opioid prescription when leaving an ED and that the majority of prescriptions involved low pill counts and almost exclusively immediate-release formulations.

But the findings of another study published in February in the New England Journal of Medicine suggests that there can be wide variation in prescribing characteristics even among emergency medicine physicians. It found emergency medicine doctors who were frequent prescribers of opioids were three times as likely to prescribe them than their colleagues within the same hospital for similar patient conditions.