RESUMO
STUDY OBJECTIVE: Opioid pain reliever prescribing at emergency department (ED) discharge has increased in the past decade but specific prescription details are lacking. Previous ED opioid pain reliever prescribing estimates relied on national survey extrapolation or prescription databases. The main goal of this study is to use a research consortium to analyze the characteristics of patients and opioid prescriptions, using a national sample of ED patients. We also aim to examine the indications for opioid pain reliever prescribing, characteristics of opioids prescribed both in the ED and at discharge, and characteristics of patients who received opioid pain relievers compared with those who did not. METHODS: This observational, multicenter, retrospective, cohort study assessed opioid pain reliever prescribing to consecutive patients presenting to the consortium EDs during 1 week in October 2012. The consortium study sites consisted of 19 EDs representing 1.4 million annual visits, varied geographically, and were predominantly academic centers. Medical records of all patients aged 18 to 90 years and discharged with an opioid pain reliever (excluding tramadol) were individually abstracted by standardized chart review by investigators for detailed analysis. Descriptive statistics were generated. RESULTS: During the study week, 27,516 patient visits were evaluated in the consortium EDs; 19,321 patients (70.2%) were discharged and 3,284 (11.9% of all patients and 17.0% of discharged patients) received an opioid pain reliever prescription. For patients prescribed an opioid pain reliever, mean age was 41 years (SD 14 years) and 1,694 (51.6%) were women. Mean initial pain score was 7.7 (SD 2.4). The most common diagnoses associated with opioid pain reliever prescribing were back pain (10.2%), abdominal pain (10.1%), and extremity fracture (7.1%) or sprain (6.5%). The most common opioid pain relievers prescribed were oxycodone (52.3%), hydrocodone (40.9%), and codeine (4.8%). Greater than 99% of pain relievers were immediate release and 90.0% were combination preparations, and the mean and median number of pills was 16.6 (SD 7.6) and 15 (interquartile range 12 to 20), respectively. CONCLUSION: In a study of ED patients treated during a single week across the country, 17% of discharged patients were prescribed opioid pain relievers. The majority of the prescriptions had small pill counts and almost exclusively immediate-release formulations.
Assuntos
Analgésicos Opioides/uso terapêutico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Dor Abdominal/tratamento farmacológico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Dor nas Costas/tratamento farmacológico , Codeína/uso terapêutico , Estudos Transversais , Feminino , Fraturas Ósseas/tratamento farmacológico , Humanos , Hidrocodona/uso terapêutico , Masculino , Pessoa de Meia-Idade , Oxicodona/uso terapêutico , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto JovemRESUMO
STUDY OBJECTIVE: To inform the development of interventions that could improve patient engagement around the risks and benefits of alternative approaches to pain management in the emergency department (ED), we seek to capture the perspectives and experiences of patients treated for pain in this setting. METHODS: Three trained interviewers conducted semistructured open-ended telephone interviews with patients discharged from a single urban academic ED after presenting with acute pain related to fracture, renal colic, or musculoskeletal back injury. We recruited subjects until achieving thematic saturation according to periodic review of the interview transcripts. Interviews were audio recorded, professionally transcribed, and uploaded into QSR NVivo (version 10.0) for coding and analysis using modified grounded theory. An interdisciplinary team double coded the data and convened to review emerging themes, ensure interrater reliability, and establish consensus on discrepancies. RESULTS: We had 23 completed subject interviews, the majority of which were women. Interrater reliability for coding exceeded 90%. The major themes elicited centered on domains of patient awareness of the potential for opioid dependence and patient-provider communication relating to pain management. From the patient perspective, emergency physicians typically do not present alternative pain management options or discuss the risks of opioid dependence. Patients with negative experiences related to pain management describe deficiencies in patient-provider communication leading to misunderstanding of clinical diagnoses, fragmentation of care among their health care providers, and a desire to be involved in the decisionmaking process around their pain management. Patients with positive experiences commented on regular communication with their care team, rapid pain management, and the empathetic nature of their care providers. Patients communicate fears about the risks of opioid addiction, beliefs that following a prescribed opioid regimen is protective of developing opioid dependence, and an understanding of the broader tensions that providers face relating to the prescription of opioid therapy. CONCLUSION: Patients identified a deficit of communication around opioid risk and pain management options in the ED.
Assuntos
Dor Aguda/tratamento farmacológico , Manejo da Dor/métodos , Adolescente , Adulto , Idoso , Comunicação , Tomada de Decisões , Serviço Hospitalar de Emergência , Feminino , Teoria Fundamentada , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/etiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Manejo da Dor/efeitos adversos , Participação do Paciente/psicologia , Adulto JovemRESUMO
STUDY OBJECTIVE: An increase in prescriptions for opioid pain medications has coincided with increasing opioid overdose deaths. Guidelines designed to optimize opioid prescriptions written in the emergency department have been implemented, with substantial controversy. Little is known about how physicians perceive and apply these guidelines. We seek to identify key themes about emergency physicians' definition, awareness, use, and opinions of opioid-prescribing guidelines. METHODS: We conducted semistructured qualitative interviews with a convenience sample of 61 emergency physicians attending the American College of Emergency Physicians Scientific Assembly (October 2012, Denver, CO). Participants varied with respect to age, sex, geographic region, practice setting, and years of practice experience. We analyzed the interview content with modified grounded theory, an iterative coding process to identify patterns of responses and derive key themes. The study team examined discrepancies in the coding process to ensure reliability and establish consensus. RESULTS: When aware of opioid-prescribing guidelines, emergency physicians often defined them as policies developed by individual hospitals that sometimes reflected guidelines at the state or national level. Guidelines were primarily used by physicians to communicate decisions to limit prescriptions to patients on discharge rather than as tools for decisionmaking. Attitudes toward guidelines varied with regard to general attitudes toward opioid medications, as well as the perceived effects of guidelines on physician autonomy, public health, liability, and patient diversion. CONCLUSION: These exploratory findings suggest that hospital-based opioid guidelines complement and occasionally supersede state and national guidelines and that emergency physicians apply guidelines primarily as communication tools. The perspectives of providers should inform future policy actions that seek to address the problem of opioid abuse and overdose through practice guidelines.