American College of Emergency Physicians

Compared to other medical settings, emergency patients who are prescribed opioids for the first time in the ED are less likely to become long-term users and more likely to be prescribed these powerful painkillers in accordance with the Centers for Disease Control and Prevention (CDC) guidelines, according to a paper analyzing 5.2 million prescriptions for opioids that was published online on Sept. 26 in Annals of Emergency Medicine ("Opioid Prescribing for Opioid-Naïve Patients in Emergency Department and Other Settings: Characteristics of Prescriptions and Association with Long-Term Use").

"Our paper lays to rest the notion that emergency physicians are handing out opioids like candy," said lead study author Molly Moore Jeffery, PhD, scientific director of the Mayo Clinic Division of Emergency Medicine Research in Rochester, Minn. "Close adherence to prescribing guidelines may help explain why the progression to long-term opioid use is so much lower in the ER. Most opioid prescriptions written in the emergency department are for shorter duration, written for lower daily doses and less likely to be for long-acting formulations."

In the emergency department, opioid prescriptions exceeding 7 days were 84 to 91 percent (depending on insurance status) lower than in non-emergency settings. Prescriptions from the ER were 23 to 37 percent less likely to exceed 50 morphine milligram equivalents and 33 to 54 percent less likely to exceed 90 morphine milligram equivalents. Prescriptions from the ER were 86 to 92 percent less likely to be written for long-acting or extended-release formulations than those attributed to non-emergency settings.

Regardless of insurance status, patients receiving opioid prescriptions in the emergency department were less likely to progress to long-term opioid use. For patients seen in the ER, 1.1 percent with private insurance, 3.1 percent with Medicare and 6.2 percent with disabled Medicare progressed to long-term use. Put another way, patients with commercial insurance were 46 percent less likely to progress to long-term opioid use, Medicare patients age 65 and older were 56 percent less likely to progress to long-term opioid use and patients with disabled Medicare were 58 percent less likely to progress to long-term use if they received an opioid prescription in the emergency department.

"Over time, prescriptions written in the ER for high dose opioids decreased between 2009 and 2011," said Jeffery. "Less than 5 percent of opioid prescriptions from the ER exceeded 7 days, which is much lower than the percentage in non-emergency settings. Further research should explore how we can replicate the success of opioid prescribing in emergency departments in other medical settings."

Workers Compensation Research Institute

As states institute numerous opioid policies and initiatives to combat the opioid epidemic, a new study from the Workers Compensation Research Institute (WCRI) observed considerable decreases in the prevalence of longer-term dispensing of opioids to injured workers in a number of states studied.

The study, Longer-Term Dispensing of Opioids, 4th Edition, examines the prevalence and trends of longer-term dispensing of opioids in 26 state workers' compensation systems. It also documents how often the services (including drug testing, psychological evaluation and treatment) recommended by treatment guidelines were used for managing chronic opioid therapy.

"Research finds that high doses and prolonged use of opioids may lead to addiction, increased disability or work loss, and even death," said Ramona Tanabe, WCRI's executive vice president and counsel. "The information in this report can help policymakers and other stakeholders compare the trend of longer-term dispensing of opioids in their state to other states, and learn what policy tools are available to reduce unnecessary opioid use."

The following is a sample of the study's major findings:

• The frequency of claims that received opioids on a longer-term basis decreased more than 4 percentage points in Kentucky and New York. The same measure decreased 2-3 percentage points in several other states (Kansas, Massachusetts, Michigan, Minnesota, and Tennessee). Noticeable decreases in the longer-term dispensing of opioids were also seen in several other states, including California, Florida, and Texas, with reductions of 1-2 percentage points.
• Among claims with injuries in 2013 that were observed over a two-year time period ending March 2015, longer-term dispensing of opioids was most prevalent in Louisiana--1 in 6 injured workers with opioid prescriptions were identified as receiving longer-term opioids. Compared with most study states, the number was also higher in California, Georgia, North Carolina, Pennsylvania, South Carolina, and Texas. By contrast, about 1 in 25 injured workers with opioid prescriptions received them on a longer-term basis in Indiana, Kansas, Missouri, Nevada, New Jersey, and Wisconsin.
• The study continued to find that fewer than expected injured workers who received opioids on a longer-term basis had certain services recommended by treatment guidelines for chronic opioid management. For example, in 19 out of 26 states, less than 10 percent of injured workers with longer-term opioids received psychological evaluations.

This study used data comprising over 400,000 nonsurgical workers' compensation claims with more than seven days of lost time, and over 2 million prescriptions are associated with these claims from 26 states. These claims had injuries in 2010 and 2013 and received on average up to 24 months of medical treatment. The sample of claims in the study represents 36-69 percent of workers' compensation claims in each state.

The 26 states in the study are Arkansas, California, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Jersey, New York, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Wisconsin.

To learn more about this study or to purchase a copy, visit https://www.wcrinet.org/reports/longer-term-dispensing-of-opioids.