Efficacy of Prescription Guidelines on Opioid Prescriptions in the ED

As described in a previous Urgent Matters blog post, opioid prescriptions in the emergency department (ED) have the potential to cause long-term opioid use (defined as 180 days or more of opioids within 12 months of the index ED visit). Further, prescription opioids continue to be the number one cause of drug overdose deaths in the US.[1] These trends indicate a dire need for effective interventions to curb unnecessary opioid prescriptions and prevent opioid abuse by patients.

A recent study in the Annals of Emergency Medicine examines the effects of one such intervention: opioid prescribing guidelines. Specifically, the study examined opioid prescription rates by ED physicians in Ohio, comparing pre and post guideline data.[2]  The goal was to determine whether the implementation of Ohio’s April 2012 opioid prescription guidelines for ED physicians reduced the number of opioid prescriptions by ED physicians.

Researchers utilized data from Ohio’s prescription drug monitoring program from 2010 – 2014, and conducted an interrupted time series analysis. Ohio’s Prescription Drug Monitoring Program includes all prescriptions for schedule II to IV medications dispensed by a pharmacy within the state. Prescriptions written in Ohio but dispensed outside the state were not included. The 5 most commonly prescribed opioids (hydrocodone, oxycodone, tramadol, codeine, and hydromorphone) were examined in this study, and prescriptions counted were limited to those prescribed by physicians with a primary specialty of emergency medicine, pediatric emergency medicine, and sports medicine. Orthopedic surgery opioid prescriptions were utilized as a control against confounding variables, primarily from opioid-related interventions initiated in parallel with the new guidelines.

Three measurements were followed in the study: 1) Total opioid prescriptions in Ohio per month by ED physicians 2) Total morphine milligram equivalents contained in these monthly prescription totals 3) Number of opioid prescriptions greater than 3 days’ duration (specifically discouraged by guidelines). The data in January of 2010 showed that total opioid prescriptions dispensed by all ED physicians in Ohio declined by 0.31% per month, which than changed to a 11.98% decrease per month after guideline implementation, starting April of 2012. Total morphine milligram equivalents improved from a 0.29% decrease per month to 17.36% decrease per month. Opioid prescriptions greater than 3 days’ duration improved from 0.04% per month to 11.2% per month. Further, the rate of decline in all three of these measures continued to decline at approximately 0.9% per month. The graphs below depict total prescription trends when stratified into the 5 most commonly prescribed opioids. A, B, C, D, and E represent Hydrocodone, Oxycodone, Tramadol, Codeine, and Hydromorphone, respectively.

SOURCE: Scott G. Weiner et al., “The Effect of Opioid Prescribing Guidelines on Prescriptions by Emergency Physicians in Ohio,” Annals of Emergency Medicine, May 2017, doi:10.1016/j.annemergmed.2017.03.057.

As demonstrated by the downward shift after the May 2012 time point, all five opioids displayed a reduction in number of prescriptions after the guidelines were implemented. The steeper slopes also demonstrate an increased rate of decline in opioid prescriptions post-guidelines.

There were several limitations to this study, including possible data entry errors, a focus on a specialty representing only 5% of total opioid prescriptions, and limited generalizability as a statewide study. However, this research suggests promise for using guidelines, both within and outside the specialty of emergency medicine, as one effective tool for combating the opioid epidemic.