National Variation in Opioid Prescribing and Risk of Prolonged Use for Opioid-Naive Patients Treated in the Emergency Department for Ankle Sprains - 25/07/18

Doi : 10.1016/j.annemergmed.2018.06.003

M. Kit Delgado, MD, MS ^a,^c,^d,^e,^f,^⁎ , Yanlan Huang, MS ^b,^f, Zachary Meisel, MD, MS ^a,^e,^f, Sean Hennessy, PharmD, PhD ^c,^f, Michael Yokell, MD ^a, Daniel Polsky, PhD ^b,^f,^g, Jeanmarie Perrone, MD ^a,^f
^a Department of Emergency Medicine, Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia, PA
^b Department of Medicine, Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA
^c Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
^d Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia PA
^e Penn Injury Science Center, University of Pennsylvania, Philadelphia PA
^f Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia PA
^g Department of Health Care Management and Economics, Wharton School, University of Pennsylvania, Philadelphia PA

^∗Corresponding Author.

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Abstract

Study objective

To inform opioid stewardship efforts, we describe the variation in emergency department (ED) opioid prescribing for a common minor injury, ankle sprain, and determine the association between initial opioid prescription intensity and transition to prolonged opioid use.

Methods

We analyzed 2011 to 2015 US private insurance claims (Optum Clinformatics DataMart) for ED-treated ankle sprains among opioid-naive patients older than 18 years. We determined the patient- and state-level variation in the opioid prescription rate and characteristics, and the risk-adjusted association between total morphine milligram equivalents (MMEs) of the prescription and transition to prolonged use (filling 4 or more opioid prescriptions 30 to 180 days after the index visit).

Results

A total of 30,832 patients met inclusion criteria. Of these patients, 25.1% received an opioid prescription with a median total MME of 100 (interquartile range 75 to 113), tablet quantity of 15 (interquartile range 12 to 20), and days supplied of 3 (interquartile range 2 to 4). State-level prescribing rates ranged from 2.8% in North Dakota to 40.0% in Arkansas. Among patients who received a total MME of greater than 225 (equivalent to >30 tabs of oxycodone 5 mg), the adjusted rate of prolonged opioid use was 4.9% (95% CI 1.8% to 8.1%) compared with 1.1% (95% CI 0.7% to 1.5%) among those who received at total MME of 75 and 0.5% (95% CI 0.4% to 0.6%) among those who did not fill an opioid prescription.

Conclusion

Opioid prescribing for ED patients treated for ankle sprains is common and highly variable. Although infrequent in this population, prescriptions greater than 225 MME were associated with higher rates of prolonged opioid use. This is concerning because these prescriptions could still fall within 5- or 7-day supply limit policies aimed at promoting safer opioid prescribing.

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Plan

Introduction

Background

Importance

Goals of This Investigation

Materials and Methods

Selection of Participants

Outcome Measures

Primary Data Analysis

Results

Characteristics of Study Subjects

Main Results

Limitations

Discussion

	Please see page XX for the Editor’s Capsule Summary of this article.
	Supervising editor: Donald M. Yealy, MD
	Author contributions: MKD, JP, ZM, and DP conceived the study and obtained research funding. MKD and DP acquired the data. MKD and YH conducted the analysis. DP and SH provided statistical guidance and supervised the analysis. All authors interpreted the results. MKD and MY drafted the article. All authors contributed to its critical revision. MKD takes responsibility for the paper as a whole.
	All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
	Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). This research was supported by the National Institute on Drug Abuse and the National Institute of Child Health and Human Development of the National Institutes of Health under awards P30DA040500 (Drs. Delgado, Perrone, Meisel, and Polsky) and K23HD090272001 (Dr. Delgado), and by the Leonard Davis Institute of Health Economics at the University of Pennsylvania. Dr. Delgado reports receiving an honorarium for participating in an expert roundtable on innovative solutions for pain management convened by the United Health Group.
	The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.