Continued opioid use following an emergency department presentation for low back pain

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.

Continued Opioid Use and Adverse Events Following Provision of Opioids for Musculoskeletal Pain in the Emergency Department: A Systematic Review and Meta-Analysis

“…Seven of the 72 included studies [ 56 , 59 , 60 , 62 , 71 , 80 , 87 ] were scored at a high overall risk of bias (eTable 3); all investigated opioid-related adverse events. More than one-third of included studies (25 studies) [ 35 , 36 , 45 , 47 , 51 , 53 , 56 , 57 , 59 , 62 , 63 , 67 , 71 , 73 , 75 , 77 , 80 , 85 , 87 , 88 , 90 , 92 , 94 , 95 , 101 ] were considered as having high or unsure risk of attribution bias due to the lack of reporting of loss to follow-up in randomised controlled trials or data completion rate not reported in observational studies.…”

Behavioural ‘nudging’ interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial

“…A previous study of patients presenting to ED with low back pain suggests 31.7% (95% CI 22.9 to 41.6) 34 received opioid prescription at discharge and 30.3% (95% CI 23.7 to 38.0) received non-indicated lumbar imaging. 35 To detect an effect of the patient nudges or clinician nudges on the number and proportion of encounters involving low-value care, with an absolute difference of 10% (eg, event rate 30% in the control hospitals vs event rate 20% in intervention hospitals) and with 80% power, alpha set at 0.05, assuming an intraclass correlation coefficient (ICC) of 0.10 and an intraperiod correlation (IPC) of 0.09 (ie, between the before and after periods, within each site) and accounting for variable cluster sizes, we would require 2416 encounters for back pain due to a musculoskeletal condition across 8 sites, over a 9-month trial period (ie, ~302 encounters per site, over 3-month baseline and 6-month intervention period).…”

Emergency Department Management of Low Back Pain: A Comparative Review of Guidelines and Practices

“…There is widespread agreement on the limited use of opioids and their detrimental long-term effects. Despite recommendations against first-line use of opioids, however, there is a broad acknowledgment of overprescription and chronic use of opioids for patients in emergency departments [ 18 ] and following discharge [ 26 ]. We found no consensus on the reason for this discrepancy.…”