D ATA D R I V E N . P O L I C Y F O C U S E D LDI ResearchBRIEF Research to Improve the Nation’s Health System 2018 . No. 13 NATIONAL VARIATION IN OPIOID PRESCRIBING AND RISK OF PROLONGED USE FOR OPIOID-NAIVE PATIENTS TREATED IN THE EMERGENCY DEPARTMENT FOR ANKLE SPRAINS M. Kit Delgado, Yanlan Huang, Zachary Meisel, Sean Hennessy, Michael Yokell, Daniel Polsky, Jeanmarie Perrone Annals of Emergency Medicine — available online July 24, 2018 KEYFINDINGS Between 2011 and 2015, nearly one in four patients with ankle sprains were prescribed opioids in the emergency department. The overall prescribing rate declined during the study period, but varied significantly by state, ranging from 2.8% in North Dakota to 40% in Arkansas. Patients prescribed the largest amounts of opioid were nearly five times more likely to transition to continued use as those prescribed lesser amounts. THE QUESTION THE FINDINGS Long-term opioid use often begins with treatment of acute pain. Most The study included 30,832 patients treated in the ED for an ankle sprain patients prescribed opioids for acute pain are left with extra opioid tablets, who had not filled a prescription for opioids in the previous six months. which present a risk for diversion or misuse. Furthermore, most people The overall prescription rate declined from 28.1% in 2011 to 20.4% in in the U.S. who have misused prescription opioids were given them by 2015. The national median rate was 24.1%. Hydrocodone was the most a friend, family member, or a doctor, and most who abuse heroin first commonly prescribed opioid (64.9%), followed by tramadol (16.2%), abused prescriptions opioids. In response to the ongoing epidemic of oxycodone (14.4%), and codeine (5.5%). opioid deaths, many states, insurers, pharmacy chains, and most recently the federal government have advocated supply limits on new opioid The median number of tablets prescribed per patient was 16, median prescriptions, ranging from as little as a 3-day supply to no more than a total MMEs was 100, and median days supplied was three. Less than 7-day supply. Whether these policies will reduce the number of opioid five percent of patients were given more than 225 MMEs (equivalent to tablets entering the community, and/or limit the number of patients more than 30 tablets of oxycodone). Patients prescribed more than 225 transitioning to long-term use, remains unclear, as do the possible MMEs had a risk-adjusted probability of transition to continued use five unintended consequences. times greater than patients prescribed 75 MMEs or less (4.9% vs 1.1%). The probability of continued use was even greater for patients prescribed To understand current patterns of opioid prescribing for an higher-potency drugs (hydrocodone and oxycodone). Among patients uncomplicated, self-limited condition, the authors studied a national with prolonged use, most subsequent prescriptions were not associated sample of patients treated in an emergency department (ED) for an ankle with the initial ankle injury, but rather other conditions, such as headache sprain between 2011 and 2015. They analyzed private insurance claims or back pain. for opioid-naïve patients to determine patient- and state-level variation in opioid prescribing, and the association between the amount of opioid State-level prescribing rates ranged from 40% in Arkansas to 2.8% in prescribed and transition to continued use (defined as filling at least North Dakota in 2014 and 2015. The authors compared the observed four opioid prescriptions in the subsequent 30 to 180 days.) The authors prescribing rates with expected rates, taking socioeconomic, demographic standardized the amount of opioids prescribed by converting quantity of and other patient-level clinical risk factors into account. Southern states tablets and days supplied to morphine milligram equivalents (MMEs). accounted for most of the higher-than-expected prescribing rates (Figure 1). Reducing excess variation in state-level prescribing could significantly reduce the number of pills entering the community. For example, COLONIAL PENN CENTER | 3641 LOCUST WALK | PHILADELPHIA, PA 19104-6218 | LDI.UPENN.EDU | P: 215-898-5611 | F: 215-898-0229 | @PENNLDI ResearchBRIEF LDI Figure 1. Observed to expected state-level prescribing rates, 2014-2015 Since decreasing the number of leftover tablets is critical to reducing diversion and overdoses, prescribing guidelines based on tablet quantities or MMEs may be more useful. A promising approach is implementing default opioid quantities (e.g., 10 tablets) in the electronic medical record, which has been shown to significantly shift ED discharge prescribing patterns to the default quantity and is consistent with emergency department prescribing guidelines in many states. If widely adopted, default orders have the potential to decrease the number of leftover opioid tablets in the community, but still allow clinicians to adjust the orders according to their patient’s needs. Finally, there is need for clearer guidelines for pain management strategies by indication and setting, including when opioids should not be considered the first-line treatment. THE STUDY The authors analyzed claims data of 13 million privately insured enrollees in the U.S. and identified all first-time ED encounters for ankle sprains in patients older than 18 between 2011 and 2015. They excluded patients who had any other injury diagnosis, and those who had recurrent visits for ankle sprain during the study period to reduce likelihood of a severe initial reducing states’ above-average prescribing rates to the median of 24.1% injury. would result in 18,300 fewer tablets prescribed. Similarly, if states that dispensed quantities above the median reduced prescribing to match the The authors described variation in opioid prescription rate and median (16 tablets), it would result in 32,000 fewer tablets prescribed. characteristics at the patient and state levels and over time. They modeled patients’ expected probability of receiving an opioid prescription, adjusting for demographic and socioeconomic factors and prior history of drug abuse and mental illness. They then calculated THE IMPLICATIONS observed to expected state-level prescribing ratios. State-level analysis Opioid prescriptions for ankle sprain remain common and highly variable. was limited to those treated in 2014-2015, and excluded states with fewer This is concerning because ankle sprain is a minor, self-limited condition than 25 patients in the study sample. for which pain usually improves within two weeks. The findings support efforts to keep opioid-naive patients opioid naive, and to use the smallest The authors quantified the number of tablets that would be prevented quantities of opioid possible for treatment of acute pain. from entering the community from reducing excess variation by reducing states’ above-median prescribing rates to the median, and above-median Patients prescribed greater quantities of opioid were nearly five times prescription supplies to the median. Finally, they quantified the risk- more likely to transition to continued use. This points to the need to adjusted association between initial MMEs prescribed and transition to examine amounts prescribed and the risk of long-term use in other prolonged use. contexts in which prescriptions are much larger, such as for postoperative pain. By focusing on ankle sprains, which usually resolve quickly without development of chronic pain, this study suggests that prolonged use may Delgado MK, Huang Y, Meisel Z, Hennessy S, Yokell M, Polsky have been due to other factors such as patients requesting opioids as D, Perrone J. National Variation in Opioid Prescribing and Risk of default pain control, or development of misuse or dependence. Prolonged Use for Opioid-Naive Patients Treated in the Emergency Department for Ankle Sprains, Annals of Emergency Medicine, July Significant statewide variation suggests ample opportunity to reduce 2018. doi: https://doi.org/10.1016/j.annemergmed.2018.06.003 excessive prescribing. Additionally, most current guidelines are written with regard to days supplied; however, the lack of specificity about how many tablets and MMEs constitute a day’s supply is problematic. A 7-day This research is supported by a pilot grant from the Center for prescription could vary anywhere from one to 84 tablets, or 7.5 to 630 Health Economics of Treatment Interventions for Substance Use MMEs. Higher-risk prescriptions of 225 MMEs could still fall within 5- or Disorder, HCV, and HIV (CHERISH), a National Institute on Drug 7-day supply-limit policies aimed at promoting safer opioid prescribing. Abuse-funded Center of Excellence (P30DA040500). LEAD AUTHOR DR. M. KIT DELGADO M. Kit Delgado, MD, MS, is an Assistant Professor of Emergency Medicine and Epidemiology at Penn and a practicing trauma center emergency physician. He leads the Behavioral Science & Analytics For Injury Reduction (BeSAFIR) lab, which applies data science and behavioral economics for preventing injuries and improving trauma and emergency care.