189 Opioid Prescribing Habits in the Acute Emergency Department Visit: Before and After Implementation of Departmental Prescribing Guidelines

Abstract

A rise in opioid-related overdoses, opioid-related deaths and possible association with recent decreases in life expectancy has captivated national attention. This has led to increased scrutiny of outpatient opioid prescribing by physicians. There have been multiple studies of emergency department (ED) populations which examine prescriptions that are provided for home use; however, we have not discovered studies that have evaluated intravenous (IV) opioid utilization for treatment of pain in the ED. At our tertiary care ED, a set of “opioid prescribing guidelines” (OPG) was created in September 2016. The OPG includes discussion of opioid risks, intention to maximize non-opioid analgesia, transparency about reviewing the Michigan Automated Prescriptions System (MAPS), and delineation of acute and chronic pain. It is not clear if such guidelines affect the prescribing patterns of clinicians or if they encourage more “appropriate” utilization of opioid medications. The primary objective is to determine if the overall number of IV opioids and total morphine equivalents (ME) changed after initiation of the OPG. A retrospective cohort study was conducted at a single-site tertiary care center with an annual census of 130,000 ED visits. We used ED pharmacy electronic medical records to compare opioid prescribing habits before and after the adoption of departmental OPG. We included patients aged 18 years and older who presented to the ED from 2015-2017. All prescriptions of fentanyl, morphine, and hydromorphone administered from November 2015 to July 2017 were tabulated to assess temporal trends in the number of prescriptions and ME of opioid medications. August through October of 2016 were excluded from data analysis to allow a washout period surrounding the adoption of the guidelines. Poisson and ordinary linear regression analyses were employed to evaluate any difference in prescribing habits before and after adoption of the guidelines. A total of 71,430 opioid-prescribing records were analyzed over the study period. The estimated mean of opioid prescriptions per 1,000 patients in the “pre” OPG period was 1797.5 (95% CI 1747.2 to 1847.8) and 1765.8 (95% CI 1715.7 to 1815.9) in the “post” period, resulting a decrease of 31.7 (95% CI 0 to 63.9, p-value = 0.05). Moreover, among patients who received opioids while in the ED, the estimated mean of ME per patient was 8.9 (95% CI 8.6 to 9.2) in the “pre” period and 8.4 (95% CI 8.1 to 8.7) in the “post” period, resulting a decrease of 0.5 (95% CI 0.3 to 0.7, p-value < 0.001). In our ED, after adoption of department-wide OPG, the number of opioids prescribed for pain during the ED encounter decreased but was not statistically significant, while the amount of ME statistically significantly decreased over the study period. Intradepartmental prescribing guidelines may be an effective tool to empower clinicians and may lead to more judicious prescribing of opioid medications.