Conversion to Persistent or High-Risk Opioid Use After a New Prescription From the Emergency Department: Evidence From Washington Medicaid Beneficiaries

Study objective

We describe the overall risk and factors associated with transitioning to persistent opioid or high-risk use after an initial emergency department (ED) opioid prescription.

Methods

A retrospective cohort study of Washington Medicaid beneficiaries was performed with linked Medicaid and prescription drug monitoring program files. We identified adults who had no record of opioid prescriptions in the previous 12 months, and who filled a new opioid prescription within 1 day of an ED discharge in 2014. We assessed the risk of persistent opioid use or high-risk prescription fills within 12 months after the index visit. Logistic regression was used to assess the association between pertinent variables and conversion to persistent or high-risk use.

Results

Among 202,807 index ED visits, 23,381 resulted in a new opioid prescription. Of these, 13.7% led to persistent or high-risk opioid prescription fills within 12 months compared with 3.2% for patients who received no opioids at the index visit. Factors associated with increased likelihood of persistent opioid or high-risk prescription fills included a history of skeletal or connective-tissue disorder; neck, back, or dental pain; and a history of prescribed benzodiazepines. The highest conversion rates (37.3%) were observed among visits in which greater than or equal to 350 morphine milligram equivalents were prescribed. Conversion rates remained greater than 10% even among visits resulting in lower-dose opioid prescriptions.

Conclusion

Medicaid recipients are at moderate risk for conversion to persistent or high-risk opioid use after a new ED prescription. Longer or higher-dose prescriptions are associated with increased risk for conversion; however, even visits that lead to guideline-concordant prescriptions bear some risk for long-term or high-risk use.

Introduction

The United States is experiencing an epidemic of prescription drug abuse, according to the Centers for Disease Control and Prevention (CDC), with deaths from opioid use now exceeding that from motor vehicle crashes.1, 2 Deaths from prescription opioids have quadrupled since 1999.³ This epidemic has been associated with increases in opioid sales and prescribing by health care providers, resulting in opioids’ expanded availability and frequent diversion for nonmedical use.4, 5, 6 This epidemic influences metropolitan and nonmetropolitan areas, as well as all racial and ethnic groups.⁷

Editor’s Capsule Summary

What is already known on this topic

Initial opioid exposure may trigger later use and misuse.

What question this study addressed

How often do factors relate to later high-risk opioid use after emergency department (ED) discharge, and what are they?

What this study adds to our knowledge

According to 2013 to 2015 Washington State Medicaid data, for the 11.5% of patients receiving an opioid prescription within 1 day of discharge, 13.7% received ongoing or high-risk opioid prescribing in the next 12 months compared with 3.2% without initial exposure. Larger initial dosing (starting at a prescription ≥150 morphine milligram equivalents) had the most effect.

How this is relevant to clinical practice

Candidates for opioids at ED discharge, especially in higher doses, are at higher risk of later use, although the appropriate response to this observation is uncertain.

Long-term opioid use often starts with treatment for an acute, painful injury or condition.⁸ In a large representative national sample of patients without cancer who received a new opioid prescription (opioid naive), the likelihood of persistent opioid use increased with each additional day of medication supplied, starting with the third day.⁹ Approximately 8% of opioid-naive patients who were prescribed opioids within 7 days of short-stay surgery were still receiving opioids 1 year later.¹⁰ After a new opioid prescription for wisdom tooth extraction, conversion to persistent use occurred at a rate of 13 per 1,000 patients with private medical insurance.¹¹ Until recently, it was believed that patients prescribed opioids for an acute problem were unlikely to develop drug abuse or addiction.12, 13 Systematic reviews indicate that the evidence for that opinion would not meet current scientific standards.14, 15

Acute care settings, including emergency departments (EDs), are those in which clinicians and their patients must navigate between addressing pain and preventing the misuse of opioid pain medication. Prevention may be the key to addressing the epidemic because once opioid use disorder occurs, only 1 in 10 Americans receives treatment, and current treatment approaches demonstrate low rates of success.¹⁶ Emergency providers care for victims of opioid overdose, abuse, and misuse every day. Paradoxically, in terms of number of prescriptions they are also among the top prescribers of opioid medication for patients younger than 40 years.¹⁷ The risk of long-term opioid use after a first prescription for acute pain from the ED has been explored: Hoppe et al¹⁸ demonstrated that among opioid-naive patients receiving an ED opioid prescription, 12% had more opioids prescribed at 1 year. Barnett et al¹⁹ analyzed a cohort of Medicare patient visits and documented a conversion rate to persistent use between 1.2% and 1.5% after a new ED prescription. Among young adults, use of opioids through a single legitimate prescrition in high school was associated with a 33% increase in the risk of subsequent opioid misuse in a cohort followed to adulthood.²⁰ Additional studies have identified that ED overdose patients and heroin users frequently report that their initial exposure to opioids came from an ED prescription.²¹ With 42% of ED visits related to pain—combined with provider quality measures that include adequacy of pain treatment and patient satisfaction—there has been documented pressure for emergency providers to prescribe opioids to their patients.²² As safety-net providers for a vulnerable population without primary care access or continuity of care, emergency providers have embraced the responsibility for bridging patients from acute injury to follow-up care, including providing pain medications when patients cannot access traditional primary care providers for treatment of pain.

Current policies and guidelines include placing absolute limits on opioid prescription quantities and mandating provider use or enrollment with prescription drug monitoring programs to identify previous, overlapping, or high-risk prescription fills.²³ However, these policies do not consider new or low-dose opioid prescriptions. And for some individuals, even small-quantity prescriptions can lead to long-term or high-risk opioid use.⁹ Therefore, such policy interventions may not identify or protect patients for whom a new prescription for opioids may pose increased risk for conversion to long-term opioid use.

We sought to describe independent risk factors for transitioning to persistent opioid or high-risk prescription fills after an initial ED opioid prescription.