SGEM#264: Hooked On A Feeling? Opioid Use and Misuse Three Months After Emergency Department Visit for Acute Pain

Date: August 9th, 2019 Reference: Daoust et al. Opioid Use and Misuse Three Months After Emergency Department Visit for Acute Pain. AEM August 2019 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: You are taking care of a 56-year-old woman who presented to the emergency department with a Jones fracture. During your discharge discussion, you offer her a prescription for oxycodone/acetaminophen and she gets a worried look on her face and says: “I try to stay away from those medications…what if I get hooked?” You realize you are unsure what to tell her about the chances of continued opiate use after an initial prescription. Background: Opioid use and misuse have increased greatly in the past 15 years, but opioids remain a mainstay of treatment for acute pain. Some have identified the 2001 Joint Commission making pain the fifth vital sign in an attempt to address the oligoanalgesia issue as part of the opioid misuse problem. ED physicians are among the most frequent prescribers of opioids. (Volkow et al. JAMA 2011). Attempting to decrease a patient’s pain to zero is certainly well-intentioned but you have to ask yourself how many patients are being harmed by such a goal? Another question you need to ask is: Do patients want their pain to be eliminated at the expense of their level of awareness and understanding why they are in pain? We have all had patients who express concern about opioid use like the case presented.  The literature has shown that more educated patients would rather receive less opioids and live with some pain compared to less educated patients. (Platts-Mills TF, et al. Pain 2012). Several studies have looked at opioid use after an initial prescription, but many of them included a large number of patients with prior substance abuse or used prescribing databases to extrapolate recurrent use as a surrogate for misuse. ACEP has a clinical policy regarding prescribing of opioids for adult ED patients that was published in 2012 (Cantrill et al). They suggest that opioid use be carefully individualized and time-limited; that opioids are best left for patients with severe or refractory acute pain; and that exacerbations of chronic pain not be treated with opioids. Clinical Question: What is the incidence of opioid use three months after an initial prescription, and what are the reasons for consumption? Reference: Daoust et al. Opioid Use and Misuse Three Months After Emergency Department Visit for Acute Pain. AEM August 2019 This episode has a PECO not a PICO. The “I” for intervention is replaced by “E” for exposure because this is a prospective observational study looking at the relationship between an exposure (opioid prescription) and an outcome not a trial of an intervention. You can learn more about study design by going to the Center for Evidence Based Medicine website (CEBM Study Designs). * Population: Patients 18 years or older with a painful condition less than two weeks without recent (less than two weeks) opioid use * Excluded: Patients who did not speak French or English, were using opioid medication in the past two weeks prior to the ED visit, stayed in the ED for more than 48 hours before discharge home, and patients with cancer pain or who were being treated for ch...