Continued Opioid Use and Adverse Events Following Provision of Opioids for Musculoskeletal Pain in the Emergency Department: A Systematic Review and Meta-Analysis

Abstract

Background The prevalence of continued opioid use or serious adverse events (SAEs) following opioid therapy in the emergency department (ED) for musculoskeletal pain is unclear. The aim of this review was to examine the prevalence of continued opioid use and serious adverse events (SAEs) following the provision of opioids for musculoskeletal pain in the emergency department (ED) or at discharge. Methods Records were searched from MEDLINE, EMBASE and CINAHL from inception to 7 October 2022. We included randomised controlled trials and observational studies enrolling adult patients with musculoskeletal pain who were administered and/or prescribed opioids in the ED. Continued opioid use and opioid misuse data after day 4 since ED discharge were extracted. Adverse events were coded using the Common Terminology Criteria for Adverse Events (CTCAE), and those rated as grades 3–4 (severe or life-threatening) and grade 5 (death) were considered SAEs. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. Results Seventy-two studies were included. Among opioid-naïve patients who received an opioid prescription, 6.8–7.0% reported recent opioid use at 3–12 months after discharge, 4.4% filled ≥ 5 opioid prescriptions and 3.1% filled > 90-day supply of opioids within 6 months. The prevalence of SAEs was 0.02% [95% confidence interval (CI) 0, 0.2%] in the ED and 0.1% (95% CI 0, 1.5%) within 2 days. One study observed 42.9% of patients misused opioids within 30 days after discharge. Conclusions Around 7% of opioid-naïve patients with musculoskeletal pain receiving opioid therapy continue opioid use at 3–12 months after ED discharge. SAEs following ED administration of an opioid were uncommon; however, studies only monitored patients for 2 days. Protocol Registration 10.31219/osf.io/w4z3u. Supplementary Information The online version contains supplementary material available at 10.1007/s40265-023-01941-1.

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“… 3 Seven percent of opioid naïve patients prescribed an opioid for acute musculoskeletal (MSK) pain continued opioid use at 3–12 months after ED discharge. 7 Whereas acute MSK pain has been as successfully treated in the ED by non-steroidal anti-inflammatory drugs (NSAIDs). 3 , 7 NSAIDs carry risks of adverse effects such as gastrointestinal bleeding, acute stroke, myocardial infarction, congestive heart failure, cardiovascular death, hypertension, and acute renal failure, exacerbated in older patients.…”

“… 7 Whereas acute MSK pain has been as successfully treated in the ED by non-steroidal anti-inflammatory drugs (NSAIDs). 3 , 7 NSAIDs carry risks of adverse effects such as gastrointestinal bleeding, acute stroke, myocardial infarction, congestive heart failure, cardiovascular death, hypertension, and acute renal failure, exacerbated in older patients. 3 To better manage acute pain in the ED, effective low risk options are needed.…”