Opioid Prescribing in EDs Entails Low Risk for Harm

Opioid prescribing in hospitals’ emergency departments (ED) is not risk-free, but the likelihood that these prescriptions will result in harm to patients is low, new research suggests.

ED physicians are under pressure to reduce opioid prescribing because of the potential for misuse of the drugs. At the same time, they face the challenge of treating severe pain. Often, emergency physicians treat opioid-tolerant patients whose physicians have stopped prescribing opioids for them. A lack of opioid prescribing guidelines complicates prescribers’ choices.

A study of administrative data for more than 13 million ED visits indicates that the level of risk to patients when ED physicians prescribe opioids “is much lower than people think it is, and the downsides of prescribing opioids for acute pain are probably much less than the downsides of not treating acute pain,” study coauthor Grant Innes, MD, professor of emergency medicine at the University of Calgary’s Cumming School of Medicine, Calgary, Alberta, Canada, told Medscape Medical News.

The data were published February 10 in CMAJ.

A Decade of Data

The relationship between opioid prescriptions and future harms has been unclear. Between 2016 and 2021, the proportion of people who filled an opioid prescription in Alberta dropped by 35%. Yet the number of annual opioid-related deaths tripled, from 554 to 1510, largely due to sales of opioids in the illegal market, wrote the researchers. 

To examine to what extent opioid prescribing in the ED was associated with future harms, the researchers analyzed opioid prescribing at all the EDs in Alberta from 2010 to 2020. They excluded patients with cancer who received palliative care and those with prolonged opioid use. Treated patients were those who filled an opioid prescription within 72 hours after their initial visit; untreated patients did not fill the prescription. The researchers used propensity scoring to identify matched controls among untreated patients.

The 1-year primary composite outcome included opioid-related ED visits (for overdoses, for example), new opioid agonist therapy, all-cause hospital admission, and death.

Opioid prescriptions were not associated with an increase in the risk for death or overdose. Of the more than 13 million visits, 689,074 (5.3% of patients) filled an opioid prescription. Patients who received opioids had 1.4% increased risk for the primary composite outcome (17.1% vs 15.7%). This difference was driven by all-cause hospital admissions (16.4% vs 15.1%). The number needed to harm was 53.

Though there had been “a ton of research on opioids and chronic pain, there was basically none for the treatment of acute pain, particularly in EDs,” said Innes. The guidelines for treating acute pain are generic, he added. 

The team also found that certain patients were at higher risk for harm after an opioid prescription, including opioid-naïve patients, patients with other substance use disorders, patients with mental health disorders, older patients, and frequent ED users.

Interestingly, Innes said, “if you looked at people [in the control group] with substance use disorder, people with mental health disorder who didn’t get an opioid prescription from the ED, they still had very high risk of adverse outcomes. They tend to do poorly if you give them a prescription and they tend to do just as poorly if you don’t.”

Future studies should explore what kinds of opioid drugs may result in more harm and what kinds of health conditions may contribute to higher risk, the authors suggested.

Guidance Lacking

In an accompanying editorial, Donna Reynolds, MD, MSc, assistant professor of clinical public health at the University of Toronto, Toronto, Ontario, Canada, and colleagues, pointed out that the current guidance on opioid prescribing is scant and vague. They explain that there’s no universal definition of “opioid naïve,” for example.

“Does the term refer to patients who have never been prescribed or used an opioid medication — or just in the last 6-12 months?” they asked. “Does it mean those with no illicit opioid or narcotic use now or ever, or is the definition more pragmatic, such as ‘not currently taking any opioids?’ Or, given that patients requesting a repeat of a new short-course prescription from another prescriber has been identified as a risk for chronic opioid use, should patients be considered opioid naïve until their first request for a repeat prescription after a short course?”

Editorial coauthor Raoul Daoust, MD, an emergency physician and clinical professor and researcher in the Department of Family Medicine and Emergency Medicine at the University of Montreal, Montreal, Quebec, Canada, said the lack of guidelines is extremely frustrating for physicians who must straddle the line between treating pain and potentially causing harm.

Pressure has been building on emergency physicians to limit opioid prescribing since the beginning of the opioid crisis, Daoust said. “What’s frustrating is that less than 5% of the quantity of opioids prescribed every year is from the ED. But we’re the ones most visible.”

The editorialists pointed to the large numbers of circulating unused opioids and say that a promising intervention may be reducing the number prescribed, depending on the patient’s condition, and adding an expiration date for use. However, they acknowledged, the long-term impact of this approach remains to be studied.

Daoust hopes that the answer is not to stop prescribing opioids, as some centers have done. “Suffering for patients has consequences,” he noted. “They get depressed and have a poor quality of life. We have to find a balance and, like any other medication, give it to the right patient in the right quantity. There are always going to be side effects.”

The Canadian Institutes of Health Research (CIHR) provided peer-reviewed grant funding for this study. Alberta Health Services (AHS) provided secure data access, analyst time, and database preparation. Innes reported support from AHS and the CIHR. Reynolds is a volunteer member of the Canadian Task Force on Preventive Health Care. 

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News, Northwestern magazine and Nurse.com and was an editor at the Chicago Sun-Times, Cincinnati Enquirer, and St. Cloud Times.