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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 chronic pain.
- Exposure: Discharged from the ED with an opioid prescription
- Comparison: None
- Outcome: Opioid use/misuse at three months
This is an SGEMHOP episode which means we have the lead author on the show. Dr. Raoul Daoust is a Professor, Université de Montréal Emergency physician Hôpital Sacré-Cœur de Montréal
Dr. Raoul Daoust
Authors’ Conclusions: “Opioid use at the 3-month follow-up in ED patients discharged with an opioid prescription for an acute pain condition is not necessarily associated with opioid misuse; 91% of those patients consumed opioids to treat pain. Of the whole cohort, less than 1% reported using opioids for reasons other than pain. The rate of long-term opioid use reported by prescription-filling database studies should not be viewed as a proxy for incidence of opioid misuse.”
Quality Checklist for
Observational Study:
- Did the study address a clearly focused issue? Yes
- Did the authors use an appropriate method to answer their question? Yes
- Was the cohort recruited in an acceptable way? Yes
- Was the exposure accurately measured to minimize bias? No
- Was the outcome accurately measured to minimize bias? No
- Have the authors identified all-important confounding factors? Unsure
- Was the follow up of subjects complete enough? Unsure
- How precise are the results? Fairly wide 95% confidence intervals due to small numbers.
- Do you believe the results? Yes
- Can the results be applied to the local population? Unsure
- Do the results of this study fit with other available evidence? Yes
Key Results: They had 3-month follow-up data on 524 participants. The mean age was 51 years and 47% were female. The most common type of pain conditions was musculoskeletal (~40%), followed by fractures (~19%), renal colic (~18%), abdominal pain (~6%) and the rest “other”. Patients received a prescription for a median of 30 tablets of 5mg of morphine (or equivalent). Patients filled the prescriptions 94% of the time and 79% reported consuming opioids during the first two weeks after the index ED visit.
9% (47/524) patients were consuming opioids at three months
- Primary Outcome: Opioid use/misuse at three months
- 47 patients (9%, 95% CI = 7%–12%) had consumed opioids in the prior two weeks
- 34 (72%) for their initial painful complaint
- 9 (19%) for new unrelated pain
- 4 (9%) for another reason (misuse) or less than 1% (4/524)
- All had consumed opioids within two weeks of the index visit
- 47 patients (9%, 95% CI = 7%–12%) had consumed opioids in the prior two weeks
Patients who consumed opioids within two weeks of the index visit were 3.8 (95% CI = 1.2– 12.7) times more likely to consume opioids at three months than those who did not.
You can listen to the podcast on iTunes or Google Play to hear Raoul’s answers to our five nerdy questions.
1) Convenience Sample: You comment that this was a convenience sample and there is no way to determine the number of patients not identified. Can you discuss how this might have affected your results?
2) Refusal to Participate: A significant number of potential patients refused to participate. No data is presented regarding prior use of opioids in these patients. Is it possible that these patients were more likely to have prior use/misuse, and how would that have affected the interpretation of the results?
3) Lost to Follow-up: Another issue is the “lost to follow-up”. We usually like to see less than 20% and you had 18%. I learned from Dr. Heather Murray that when the effect size is smaller than the lost to follow-up, we should be more skeptical of the results. Do you have any information on the characteristics of those lost to follow-up compared to those who completed the study?
4) Recall Bias: This is a form of cognitive bias. It has been defined as “a systematic error caused by differences in the accuracy or completeness of the recollections retrieved (“recalled”) by study participants regarding events or experiences from the past” (Wikipedia). Is there any concern that the results are limited by recall bias?
5) External Validity: This was a prospective cohort study conducted in the ED of a Canadian academic Level I trauma center. The joke is that a Canadian is just an unarmed American with access to universal health care. Do you think this study has external validity to our American friends south of the boarder?
Here is a link on state-by-state opioid prescribing guidelines and one for the state of Virginia specifically.
Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusions.
SGEM Bottom Line: Only a small percent of patients who received an opioid prescription in the ED will still be using opioids months later and even less will be misusing opioids.
Case Resolution: Your patient agrees to have a prescription written and tells you that she may only fill it if her pain is severe.
Clinical Application: When discharging patients with painful complaints, be aware that the risks of future use and misuse is small but not zero and consider whether opioids are the most appropriate treatment for their pain.
Dr. Corey Heitz
What Do I Tell My Patient? There does seem to be a correlation with opioid use for a painful complaint and opioid use/misuse three months later. The majority is for the same painful complaint. It seems more likely if you use the opioids in the first two weeks of getting the prescription. If this concerns you, you can try to avoid use in the short term and use alternatives to opioids.
Keener Kontest: Last weeks’ winner was Mario Pinoli. He knew Sir William Osler, who graduate of McGill University, said: “One of the first duties of the physician is to educate the masses not to take medicine.”
Listen to the podcast to hear this weeks’ trivia question. If you know the answer, send an email to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.
SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on opioid use and misuse? Tweet your comments using #SGEMHOP. What questions do you have for Raoul and his team? Ask them on the SGEM blog. The best social media feedback will be published in AEM.
Also, don’t forget, those of you who are subscribers to Academic Emergency Medicine can head over to the AEM home page to get CME credit for this podcast and article. We will put the process on the SGEM blog:
- Go to the Wiley Health Learning website
- Register and create a log in
- Search for Academic Emergency Medicine – “August”
- Complete the five questions and submit your answers
- Please email Corey (coreyheitzmd@gmail.com) with any questions or difficulties.
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