Tailored opioid prescriptions for acute pain at ED discharge can reduce risk of misuse

2nd October 2023

Tailoring opioid prescriptions for patients discharged from an emergency department (ED) with acute pain can support recovery and help to avoid the risk of drug misuse, according to a study presented at the European Society of Emergency Medicine (EUSEM)‘s recent congress.

The study found half of patients discharged from an ED with acute pain required five tablets or fewer of morphine 5 mg or an equivalent opioid painkiller to help manage their pain and recover from their injury or condition at home.

By tailoring the number of opioid painkillers prescribed for each patient, ED clinicians can ensure the right balance between sufficient pain relief and avoiding the over-prescribing of these drugs, which can lead to dependence and abuse in some cases.

Professor Raoul Daoust, from the University of Montreal, Canada, who presented the research, said: ‘Opioids such as morphine can be very beneficial for patients suffering acute pain, for example when they have injured their neck or broken a bone. However, patients are often prescribed too many opioid tablets and that means unused tablets are available for misuse. On the other hand, since the opioid crisis, the tendency in the USA is to not prescribe opioids at all, leaving some patient in agonising pain.

‘With this research I wanted to provide a tailored approach to prescribing opioids so that patients have enough to manage their pain but almost no unused tablets available for misuse.‘

Acute pain recovery at home

Some 2,240 adult patients were recruited for the study, all of whom were treated at one of six hospital EDs in Canada for a condition that causes acute pain. They were each discharged with an opioid prescription and were asked to complete a pain medication diary for the following two weeks.

While half of patients took five 5 mg morphine tablets or fewer, the researchers noted that the number of tablets each patient required during the two-week period varied greatly according to the patient’s painful condition. For example, patients suffering from renal colic or abdominal pain needed only eight tablets and patient with broken bones needed 24 tablets.

Professor Daoust added: ‘Our findings make it possible to adapt the quantity of opioids we prescribe according to patient need. We could ask the pharmacist to also provide opioids in small portions, such as five tablets initially, because for half of patients that would be enough to last them for two weeks.’

Also commenting on the results, Professor Youri Yordanov from the St Antoine Hospital emergency department in Paris, France, who is chair of the EUSEM 2023 abstract committee but was not involved in the research, added: ‘It’s estimated that millions of people around the world are struggling with opioid addiction and more than 100,000 people die of opioid overdose every year. These drugs play an important role in emergency medicine, but we need to ensure they are prescribed wisely.

‘This study shows how opioid prescriptions could be adapted to specific acute pain conditions, and how they could be dispensed in relatively small numbers at the pharmacy to lower the chance of misuse. This research could provide a safer way to prescribe opioids that could be applied in emergency departments anywhere in the world.‘

Although widely prescribed in an emergency setting, a recent study has found that using opioids for patients with acute low back or neck pain offers no significant pain relief advantage compared to placebo.

Long-term opioid use risk in one in three patients with rheumatic and MSK conditions

19th May 2023

Patients with rheumatic and musculoskeletal conditions are particularly vulnerable to long-term opioid use, new research has found.

A study of GP research database between 2006 and 2021 found one in three of those with rheumatoid arthritis or fibromyalgia had received long-term prescriptions for the potentially addictive drugs to manage their pain.

Overall, the team analysed more than 840,000 patient records and looked at different patterns of opioid use depending on frequency and number of prescriptions.

There were 1,081,216 new episodes of opioid use among all patients with just under 17% transitioning to ‘standard’ long-term use, defined as three or more prescriptions within a 90-day period, or more than 90 days supply in the first year.

Another 11% were categorised as having ‘stringent’ opioid prescribing with 10 or more prescriptions over more than 90 days, or 120 plus days of supply in the first year.

The research also found that 22% moved onto ‘broad’ opioid prescriptions which was classed as more than three opioid prescriptions at monthly intervals in the first year.

Reporting the findings in the Annals of Rheumatic Diseases, the team said the highest proportion of long-term users were patients with fibromyalgia—27.5%, 21%, and 34% for standard, stringent and broad prescribing categories.

This was followed by those with rheumatoid arthritis (26%, 18.5%, and 32% respectively) and those with axial spondyloarthritis at 24%, 17%, and 30%.

The results also showed an increasing proportion of patients with systemic lupus erythematosus and fibromyalgia who moved from one opioid prescription to long-term prescribing between 2006 and 2019.

But the converse pattern was true in rheumatoid arthritis with a decreasing trend over the time period, although the researchers noted the overall proportion remained high at 24.5% in 2020.

Calls for opioid use optimisation

A 2019 review by Public Health England, found one in four adults were prescribed medications associated with dependence, including opioids, benzodiazepines and antidepressants.

NICE has since issued guidance on safe prescribing and withdrawal management for addictive drugs.

Dr Joyce Huang, study author and research associate in the Division of Musculoskeletal and Dermatological sciences at the University of Manchester, said: ‘Our study does not intend to stigmatise patients who use opioids.

‘We want to highlight the high frequency of long-term opioid use needs to be optimised and prevent people living with [rheumatic and musculoskeletal disorders] from opioid-related harm.’

Study lead Dr Meghna Jani, senior lecturer at the Centre for Epidemiology Versus Arthritis, said the results show that a ‘considerable proportion of patients’ with these conditions starting opioids for the first time, transition to long-term use that is much higher than people who are starting an opioid for non-cancer pain in general which is around one in seven people.

‘Because long-term opioid therapy is associated with poor health outcomes, these findings warrant vigilance when prescribing these drugs.

‘Long term use is particularly pronounced in fibromyalgia patients, who suffer chronic widespread pain for which there are no disease modifying treatment options. This is also more common than we initially thought, in rheumatoid arthritis and axial spondyloarthritis.’

A version of this story was originally published by our sister publication Pulse.

Half of paediatric opioid prescriptions deemed high risk

27th August 2021

A US analysis of over 4 million paediatric opioid prescriptions found nearly half were considered high-risk based on more than one metric.

The prescription of opioid drugs to paediatric patients, defined as those aged 0 to 17 years, can lead to not only adverse effects in the short-term, but problems in the longer-term. For example, a study in children without severe pain, found that one of every 2611 acute opioid prescriptions were followed by an opioid-related adverse event. Moreover, persistent use of opioids has been observed in nearly 5% of adolescents after surgery and which could ultimately lead to dependence. There is currently limited data on the prescription of such drugs to paediatric patients but some information derived from insurance claims suggests that 1 in 10 adolescents filled at least one opioid prescription per year. In contrast, other insurance-based studies have revealed how opioid prescribing to children and adolescents has been steadily reducing since 2012.

In trying to gain further insight of opioid prescribing, a team from the Division of General Pediatrics, University of Michigan, US, set out to assess the prevalence and safety of opioid prescriptions given to children and young adults. The team used a comprehensive prescription database that contained records for every prescription dispensed from 92% of US retail pharmacies, 70% of mail-order pharmacies and 70% of pharmacies in long-term care facilities. The team looked specifically at opioid and benzodiazepine prescriptions, excluding opioid cough and cold remedies and buprenorphine, used for substance misuse. In an effort to determine whether such prescriptions could be deemed at high-risk, the team used 6 different metrics; the proportion of prescriptions for opioid naïve patients exceeding 3 and 7-day supplies; the proportion of prescriptions dispensed for children aged 0 to 11; the proportion of opioid prescriptions given to those aged 12 to 21 years with daily dosages of > 50 morphine milligram equivalents (MME) and finally, the proportion of opioid prescriptions for adolescents, which overlapped with a benzodiazepine prescription for > 1 day and each of these metrics was derived from best-practice guidance.

Findings
The database included 4,027,701 opioid prescriptions, of which 86.6% were for patients aged 0 to 21 years, of whom 80.7% were opioid naïve. The majority of prescriptions were issued by a dentist (38.2%), followed by a surgery (23.3%), physician assistant (7.2%) and emergency department (7.1%). Overall, 3.5% of children and young adults had >1 dispensed opioid prescription. The most commonly prescribed opioid was hydrocodone (52.7%), followed by oxycodone (21.3%), codeine (13.8%) and tramadol (9.8%).

Among 3,250,443 prescriptions written for opioid naïve patients, 41.8% and 3.8% exceeded the recommended 3- and 7-day course respectively. Similarly, among 3,487,263 prescriptions for adolescents and young adults, 11.5% had a daily MME > 50 and 4.6% were co-prescribed with a benzodiazepine. In fact, 45.6% of all prescriptions were classed as being high-risk by more than one metric.
Commenting on their findings, the authors noted that the majority of prescriptions were issued by dentists and likely to have been for dental extractions although alternatives to opioid prescriptions such as non-steroidal anti-inflammatory drugs provide a similar level of pain relief. They concluded that broad-based initiatives are needed to address high-risk prescribing.

Citation
Chua KP et al. Prescribing to US children and young adults in 2019. Pediatrics. 2021