Even small quantities of opioids may increase possibility of long-term use

Patients who received their first opioid prescription for 30 or more pills for an ankle sprain were twice as likely to fill an additional opioid prescription within 3 to 6 months than those who received 15 or fewer pills, according to findings recently presented at the Society for Academic Emergency Medicine meeting.

Perspective from Lawrence Greenblatt, MD, FACP

Researchers suggest that their findings indicate the need to address when opioid medications are indicated for minor injuries and to reduce the number of pills supplied for opioid prescriptions.

M. Kit Delgado, MD, MS, assistant professor of emergency medicine and epidemiology at the University of Pennsylvania and colleagues examined the records of ED visits from 2011 to 2012 for patients with ankle sprains that had an Injury Severity Score of 1 and who had not filled an opioid prescription in the previous 6 months. Researchers determined the proportion of these visits for which the patient filled a new opioid prescription within 7 days and quantity supplied for these prescriptions at the visit- and state-level, then examined the association between quantity supplied among those who filled opioid prescriptions and filling another new prescription for opioids 90 to 180 days after the initial ED encounter, adjusting for age, comorbidities, drug, sex, state, and year.

Researchers found that of the 53,222 ED visits that met the criteria, 7.1% of the patients received an opioid prescription. Of these, the median number of hydrocodone or oxycodone pills supplied was 20 (interquartile range 15-30) with 5% receiving 60 pills or more. If all opioid prescriptions written for more than 20 pills were instead limited to 20 pills, there would have been 37,721 fewer opioid pills entering the community. Delgado and colleagues also found that when compared to those who received the smallest quantity of pills (15 pills or fewer), patients who received 30 or more pills had double the odds of additional opioid prescriptions at 90 to 180 days (aOR = 1.97; 95% CI, 1.48-2.62).

“If extrapolated more broadly to the treatment of other minor injuries, this likely translates to millions of highly addictive and unnecessary prescribed pain medications filtering into the community,” Delgado said in the release. “The study illustrates the potential benefit of laws limiting new opioid prescriptions for acute pain to no more than a 5-day supply as was recently passed in New Jersey.”

Delgado and colleagues also found a wide state-level variation in the rate of opioid prescriptions, ranging from 1.6% of cases in Delaware to 16% in Mississippi.

A study that recently appeared in MMWR suggested that the risk for chronic opioid use can be triggered in as little as 3 days. Those researchers also suggested that treatment of acute pain with opioids should be for the shortest durations possible, which is consistent with CDC’s guidelines for opioid use.

Other research recently identified six potential practices that could lead to better outcomes in chronic opioid management, including calculating progress toward achieving clinic objectives and pinpointing resources for complex patients. – by Janel Miller

Reference: Delgado, MK. et al. “National variation in opioid prescribing and risk of prolonged opioid use for opioid-naïve patients treated in the emergency department for ankle sprains.” Presented at: Society for Academic Emergency Medicine Meeting; May 16-19, 2017; Orlando, Fla.

Disclosure: Healio Family Medicine was unable to confirm researchers’ relevant financial disclosures prior to publication.

Perspective

Lawrence Greenblatt, MD, FACP

Many readers will find the most striking finding in “National variation in opioid prescribing and risk of prolonged opioid use for opioid-naïve patients treated in the emergency department for ankle sprains” is the truly remarkable variation of the rate of opioid prescribing for a minor ankle sprain. Rates varied by a factor of 10. It is important to note that, overall, 93% of the patients were managed without an initial opioid prescription. Of those who were prescribed an opioid, the median quantity of 20 doses went well beyond current recommendations from the CDC for 3 days of therapy. One must understand that these data were collected 4 to 5 years prior to the publication of the CDC guidelines. Among the patients prescribed opioids, the authors report that those receiving 15 or fewer doses had half the odds of receiving additional therapy in the 90 to 180 days post initial evaluation compared with those receiving 30 or more doses. While this may reflect a change in the patients brought on by receiving a short course of opioids, it is more likely that the patients prescribed higher quantities of opioids receive their care in communities where these medications were prescribed more liberally. In my home state of North Carolina, county-by-county variations in opioid prescribing rates can vary by a factor of 3 to 4 and correlate strongly with the risk of opioid overdose death. Prescribers are heavily influenced by local medical practice norms.

Lawrence Greenblatt, MD, FACP

Professor of Medicine, Professor of Community and Family Medicine, Duke University School of Medicine

Disclosures: Greenblatt reports no relevant financial disclosures.