Abstract
IntroductionThe U.S. opioid epidemic has highlighted the need to identify patients at risk of opioid abuse and overdose. We initiated a novel emergency department- (ED) based interventional protocol to transition our superuser patients from the ED to an outpatient chronic pain program. The objective was to evaluate the protocol’s effect on superusers’ annual ED visits. Secondary outcomes included a quantitative evaluation of statewide opioid prescriptions for these patients, unique prescribers of controlled substances, and ancillary testing.MethodsPatients were referred to the program with the following inclusion criteria: ≥ 6 visits per year to the ED; at least one visit identified by the attending physician as primarily driven by opioid-seeking behavior; and a review by a committee comprising ED administration and case management. Patients were referred to a pain management clinic and informed that they would no longer receive opioid prescriptions from visits to the ED for chronic pain complaints. Electronic medical record (EMR) alerts notified ED providers of the patient’s referral at subsequent visits. We analyzed one year of data pre- and post-referral.ResultsA total of 243 patients had one year of data post-referral for analysis. Median annual ED visits decreased from 14 to 4 (58% decrease, 95% CI [50 to 66]). We also found statistically significant decreases for these patients’ state prescription drug monitoring program (PDMP) opioid prescriptions (21 to 13), total unique controlled-substance prescribers (11 to 7), computed tomography imaging (2 to 0), radiographs (5 to 1), electrocardiograms (12 to 4), and labs run (47 to 13).ConclusionThis program and the EMR-based alerts were successful at decreasing local ED visits, annual opioid prescriptions, and hospital resource allocation for this population of patients. There is no evidence that these patients diverted their visits to neighboring EDs after being informed that they would not receive opioids at this hospital, as opioid prescriptions obtained by these patients decreased on a statewide level. This implies that individual ED protocols can have significant impact on the behavior of patients.
Highlights
The U.S opioid epidemic has highlighted the need to identify patients at risk of opioid abuse and overdose
We found statistically significant decreases for these patients’ state prescription drug monitoring program (PDMP) opioid prescriptions (21 to 13), total unique controlled-substance prescribers (11 to 7), computed tomography imaging (2 to 0), radiographs (5 to 1), electrocardiograms (12 to 4), and labs run (47 to 13)
This program and the Electronic medical record (EMR)-based alerts were successful at decreasing local emergency department- (ED) visits, annual opioid prescriptions, and hospital resource allocation for this population of patients
Summary
The U.S opioid epidemic has highlighted the need to identify patients at risk of opioid abuse and overdose. In the early 1990s there was a concerted effort by the Veterans Health Administration (VHA) and The Joint Commission to target pain management with opioids.[1] Pain quickly became the “fifth vital sign,” and opioid prescriptions escalated.[2] Between 1999 and 2010, the marketing of opioids to pharmacists, hospitals, and doctors’ offices had quadrupled, and there was a 300% increase in the prescription of opioids in the U.S.3,4. With this dramatic increase in opioid prescribing behavior, a number of serious unintended consequences were noted. Direct healthcare costs of improper and non-medical opioid prescription use is estimated to be greater than $72 billion per year.[3]
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