New research in the Canadian Medical Association Journal links emergency department opioid prescriptions to small increases in future opioid use and hospitalisations, but not death or overdose. The study highlights the need for cautious prescribing, especially in high-risk patients
The new research shed light on the complex relationship between opioid prescriptions issued in emergency departments (EDs) and subsequent patient outcomes. While the study found no increased risk of death or overdose, it did reveal a small but significant association between ED opioid prescriptions and increased future opioid use and hospital admissions.
Examining opioid prescribing patterns
The study, conducted by researchers at the University of Calgary, analysed data from over 13 million ED visits across Alberta between 2010 and 2020. Of these visits, 689,074 patients (5.3%) filled an opioid prescription. The research team sought to understand the long-term effects of these ED opioid prescriptions, specifically looking at the risk of adverse outcomes like overdose, further opioid prescriptions, and hospitalisations within one year of the initial ED visit.
Key findings: A nuanced picture of opioid prescription
The study’s findings paint a nuanced picture of the risks and benefits associated with opioid prescribing in the ED. While the researchers found no link between ED opioid prescriptions and an increased risk of death or overdose, they did observe a small but statistically significant increase in both subsequent opioid prescriptions and hospital admissions among patients who received opioids in the ED. Specifically, 4.5% of opioid-treated patients received additional opioid prescriptions within a year, compared to 3.3% of untreated controls. Similarly, 16.4% of opioid-treated patients required hospital admission compared to 15.1% of untreated controls.
Understanding the context: Balancing pain management and risk
The authors acknowledge the difficult position emergency physicians face. They are under increasing pressure to reduce opioid prescribing, yet they must effectively manage severe pain and treat patients with opioid tolerance who may have difficulty accessing prescriptions from their primary physicians.
“Emergency physicians face growing pressure to curtail opioid prescribing but must manage severe pain and treat opioid-tolerant patients who can no longer access opioids from their physicians,” writes Dr. Grant Innes, professor of emergency medicine at the University of Calgary and lead author of the study. “There is little research to guide them.”
Identifying high-risk groups
The research highlights the importance of patient-specific risk assessment. The study found that certain patient groups were more likely to experience adverse outcomes following an ED opioid prescription.
These high-risk groups include opioid-naive patients, older adults, patients with multiple health conditions, and frequent ED users. This suggests that clinicians should exercise greater caution when prescribing opioids to these individuals.
Implications for clinical practice
The study authors emphasize that while single opioid prescriptions in the ED are not without risk, the probability of harm is low and likely outweighed by the benefits of effective pain management in acute situations. They recommend that physicians consider the concept of patient-specific incremental risks when prescribing opioids for acute pain and exercise caution when prescribing for high-risk groups.
The need for further research on opioids and their prescription
The researchers also call for further investigation into several key areas. They suggest that future studies should examine the effects of different types of opioid medications, as these may carry varying levels of risk. Additionally, they recommend further research to identify specific health conditions where opioid risk is either increased or decreased.
Commentary calls for more research and guidance
A related commentary published in the same issue of CMAJ echoes the need for more research and guidance in this area. Dr. Donna Reynolds, a family physician and acting co-chair of the Canadian Task Force on Preventive Health Care, and her co-authors emphasize the importance of bridging the research gap to inform best practices for acute pain management.
“Research and guidance in this area is long overdue,” they write, “and only filling this research gap will allow acute pain prescribers and their patients to consider how best to ameliorate pain while minimizing potential harms related to opioid prescription.” This research underscores the need for a balanced approach to pain management in the ED, one that effectively addresses acute pain while minimizing the potential long-term risks associated with opioid prescriptions.
