In response to skyrocketing painkiller prescriptions and opioid abuse, state legislatures and hospitals around the United States have focused their energy on tightening emergency room prescribing guidelines. However, a new study published in Annals of Emergency Medicine finds that these efforts might be misguided, or at least insufficient: It reports a significant majority of prescribed opioids came from office-based doctors (that is, those who prescribe in an outpatient setting) rather than emergency departments.
"The role in the emergency department might be less of needing to be tightly regulated about prescribing these drugs and more of a place that physicians could be looking for people who are at risk for abuse," says study author Sarah Axeen, an assistant professor at the University of Southern California's Keck School of Medicine. "Looking for patients at risk might be more of an appropriate role for the [emergency department] than these sort of very strict regulations about prescribing drugs."
In 2014, more than 18,000 people died as a result of opioid use, and that number continued to rise in 2015. The Centers for Disease Control and Prevention has recognized the role of office-based doctors in overprescribing, and issued guidelines recommending better prescribing practices. Although doctor-based prescriptions have been on the decline since 2010, prescription rates still remain high compared to past decades.
The study, which performed a retrospective analysis of the Medical Expenditure Panel Survey from 1996 to 2012, finds the majority of the prescription growth could be attributed to office visits and prescription refills. Emergency department prescriptions actually declined during this period. Over the 17-year period, overall prescriptions increased 471 percent, according to the study. However, the share of opioid prescriptions attributed to emergency rooms declined from 7.4 percent to 4.4 percent.
Axeen was struck by the stark disparity in how the high-end distribution users—the top 5 percent of most frequent opioid users in the total quantity of prescribed drugs—are getting their drugs. Just 2.4 percent of high-end users got their opioid prescriptions through an emergency department; 87.9 percent come from a doctor's office.
"We're seeing these high-risk users having medical events," Axeen says. "There are opportunities to intervene with them. Maybe there should be a concomitant focus on, 'Well, you're already a high-risk user, maybe let's try to push you toward treatment or alternative therapies.'"
In October, President Donald Trump declared the opioid crisis a public-health emergency. States such as Massachusetts and West Virginia have implemented insurance programs to address the number of opioid cases in the states and develop treatment strategies. There is more movement and recognition to not only stop prescriptions, but to offer treatment to users and find solutions.
"In general the regulatory motion is in the right direction," Axeen says, "but it is good to see the research that backs up having regulations aimed more at repeated and chronic prescribing of these drugs."