Objective To describe the overall risk and factors associated with transitioning to persistent opioid or high-risk use after an initial emergency department (ED) opioid prescription. Methods A retrospective cohort study of Washington Medicaid beneficiaries was performed using linked Medicaid and prescription drug monitoring program files. We identified adults who had no record of opioid prescriptions in the prior 12 months, and who filled a new opioid prescription within one day of an ED discharge in 2014. We assessed the risk of persistent opioid use or high-risk prescription fills within 12 months after the index visit. Logistic regression was used to assess the association between pertinent variables and conversion to persistent or high-risk use. Results Among 202,807 index ED visits, 23,381 resulted in a new opioid prescription. Of these, 13.7% led to persistent or high-risk opioid prescription fills within 12 months, compared to 3.2% for those who received no opioids at the index visit. Factors associated with increased likelihood of persistent opioid or high-risk prescription fills include a history of skeletal or connective-tissue disorder, neck, back or dental pain, and a history of prescribed benzodiazepines. The highest conversion rates (37.3%) were seen among visits in which ≥350 morphine milligram equivalents were prescribed. Conversion rates remained over 10% even among visits resulting in lower dose opioid prescriptions. Conclusion Medicaid recipients are at moderate risk for conversion to persistent or high-risk opioid use after a new ED prescription. Longer or higher dose prescriptions are associated with increased risk for conversion, however, even visits which lead to guideline concordant prescriptions bear some risk for long term or high-risk use.

An automated prescription drug monitoring program query intervention was not associated with reductions in ED opioid prescribing or quantities, even in patients with previous high-risk opioid use.

Objective Washington State mandated seven hospital “best practices” in July 2012, several of which may affect ED opioid prescribing and provide a policy template for addressing the opioid prescription epidemic. We tested the hypothesis that the mandates would reduce opioid dispensing after an ED visit. We further assessed for a selective effect in patients with prior risky or chronic opioid use. Methods We performed a retrospective, observational analysis of ED visits by Medicaid fee-for service beneficiaries in Washington State, between July 1, 2011 to June 30, 2013. We used an interrupted time series design to control for temporal trends and patient characteristics. The primary outcome was any opioid dispensing within 3 days after an ED visit. The secondary outcome was total morphine milligram equivalents (MMEs) dispensed within 3 days. Results We analyzed 266,614 ED visits. Mandates were associated with a small reduction in opioid dispensing after an ED visit (−1.5%, 95%CI: −2.8% to −0.15%). The mandates were associated with decreased opioid dispensing in 42,496 ED visits by patients with prior risky opioid use behavior (−4.7%, 95%CI: −7.1% to −2.3%) and in 20,238 visits by patients with chronic opioid use (−3.6%, 95%CI: −5.6% to −1.7%). Mandates were not associated with reductions in MMEs per dispense in the overall cohort or in either subgroup. Conclusions Washington state “best practice” mandates were associated with small but non-selective reductions in opioid prescribing rates. States should focus on alternative policies to further reduce opioid dispensing in subgroups of high risk and chronic users.

EHR data locations were inaccurate 30% of the time, leading to improvement in overall modeling from a gold standard from chart review for individual diagnoses. However, the impact on identification of the highest risk patients was minor, and combining data from different EHR locations was equivalent to gold standard performance. The reviewer's ability to identify a diagnosis as correct was influenced by a variety of factors, including completeness, temporality, and perceived accuracy of chart data.

A minority of opioid prescribers to Medicaid beneficiaries used the PDMP. We identified variations in PDMP use by prescriber specialty. Interventions to increase PDMP queries should target both PDMP registration and PDMP use after registration, as well as specialties with current low use rates.