Conversion to Persistent or High-Risk Opioid Use After a New Prescription From the Emergency Department: Evidence From Washington Medicaid Beneficiaries

Abstract

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.

Effect of an Electronic Health Record “Nudge” on Opioid Prescribing and Electronic Health Record Keystrokes in Ambulatory Care

“…9 Higher quantities and doses are associated with increased risk of overdose 6,7 and, among opioid-naive patients, with higher risk of progression to long-term use. [10][11][12] In 2016, the Centers for Disease Control and Prevention (CDC) published an influential Guideline for Prescribing Opioids for Chronic Pain 6,7 that recommended (among other measures) starting opioid-naïve patients with acute pain on the lowest effective dose, generally 3-7 days' supply. Multiple policy initiatives have also promoted lower-risk prescribing, ranging from prescription drug monitoring programs (PDMPs) 13 to insurance coverage limitations.…”

Opioid Prescription Patterns for Discharged Patients from the Emergency Department

“…Rising trends in ED opioid prescriptions is a public health concern, given studies have demonstrated the potential for these medications to be misused, diverted, or lead to opioid related deaths [ 19 , 20 ]. The data within this study elucidate recent trends in opioid prescriptions in relation to common diagnoses associated with opioid prescriptions, amount and type of opioid prescribed, and provider type (i.e., attending physician, NP/PA, and resident).…”

Oxycodone prescribing in the emergency department during the opioid crisis

“…13 This strategy may reduce the risk of persistent use, which has been associated with prescriptions for larger volumes of tablets. 7 It also restricts the volume of unused opioids available in the community for misuse by others. In our EDs however, over three-quarters of discharge prescriptions had no reduction in pack size, allowing for a maximum supply of tablets under the PBS to be dispensed.…”

“…A recommended safeguard is to limit the number of opioid tablets supplied, to match the expected duration of severe pain 13. This strategy may reduce the risk of persistent use, which has been associated with prescriptions for larger volumes of tablets 7. It also restricts the volume of unused opioids available in the community for misuse by others.…”

“…EDs were identified as a significant source of inappropriate opioid prescriptions into the community 5. Furthermore, the prescription of an opioid medication on discharge from the ED was associated with both the development of persistent opioid use7 and increased costs to the healthcare system 8. This resulted in the implementation of mandatory ED prescribing guidelines in parts of the USA, which have been successful in reducing the volume of hospital‐supplied opioid medications 8…”