Opioid Deprescribing in Emergency Medicine—A Tool in an Expanding Toolkit

Abstract

The opioid crisis has been a top public health priority for more than a decade. Although its latest evolution involves epidemic-level deaths from illicitly manufactured fentanyl and its analogues, the origin of the crisis can be definitively traced to the overprescribing of prescription opioids. Although broad-based efforts across all specialties have resulted in substantial reductions in opioid prescribing, the study by Smith et al 1 demonstrates that efforts in their emergency department (ED) outpaced any secular trend. Their study evaluated opioid prescribing in an urban, academic ED and found a 66.3% decline between 2013 and 2018 for a variety of painful conditions, a rate substantially greater than those reported in previous studies and in national data.When initial reports about opioid overprescribing emerged, government-derived data highlighted emergency medicine as a top-prescribing specialty based on the number of prescriptions written. However, later work demonstrated that, despite evaluating and treating substantial numbers of patients with pain, ED opioid prescriptions were typically for small quantities (eg, a mean of 17 tablets), 2 highlighting that, even in earlier eras, emergency physicians were reticent to prescribe opioids for more than a few days. Although ED prescribing has not been the primary driver of the epidemic of opioid use disorder (OUD), hyperalgesia, overdose, and death associated with prescription and illicit opioids, there remain opportunities for improvement.

Patient outcomes after opioid dose reduction among patients with chronic opioid therapy

“…In fact, some healthcare professionals have identified multilevel barriers to deprescribing (ie, dose reduction and discontinuation), 26 whereas others have suggested opioid "stewardship" toolkits to reduce opioid harms especially in high-prescribing settings (eg, emergency departments). 33 Few studies have examined unintended effects of abrupt discontinuation on patient outcomes. Patients on chronic opioid therapy in one primary care clinic who discontinued opioid prescriptions had nearly a 3-fold increase in overdose risk.…”

“…In fact, some healthcare professionals have identified multilevel barriers to deprescribing (ie, dose reduction and discontinuation), 26 whereas others have suggested opioid “stewardship” toolkits to reduce opioid harms especially in high-prescribing settings (eg, emergency departments). 33…”

Trends in pediatric prescription-opioid overdoses in U.S. emergency departments from 2008–2020: An epidemiologic study of pediatric opioid overdose ED visits

“…In compliance with the HCUP data use agreement, result table cell values of 1-10 were suppressed to avoid individual identification. SAS software version 9.4 (SAS Institute, Cary, NC) computed weighted counts and 95% CI [23] and ggplot2, an open-source data visualization package in R v1.3, plotted all figures [31][32][33][34].…”

“…Many states developed prescription guidelines to prevent opioid overuse [ 17 , 22 ]. Some U.S. EDs have experimented with decreasing opioid prescribing to combat subsequent opioid misuse [ 23 ]. In addition, new approaches alerting physicians of opioid-related deaths of their patients have made physicians more conservative in their prescribing practices, including opioids, even if their prescription was irrelevant to the patient’s death [ 24 ].…”