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Beyond Fractures: Which Diagnoses Contribute to Emergency Department Opioid Discharge Prescribing?

Brad D. Gordon, MD, MS – Associate Professor, Regions Emergency Medicine Residency

Bjorn Westgard, MD, PhD – Assistant Professor, HealthPartners/University of Minnesota

Andrew R. Zinkel, MD, MBA – Medical Director, Assistant Professor, HealthPartners, University of Minnesota

Sarah A. Matzdorf – Clinical Research Assistant, Regions Hospital/HealthPartners

Kyra Wicklund, MPH – Clinical Research Coordinator, Regions Hospital/HealthPartners

Michael Zwank, MD – Associate Professor, Regions Hospital

Brad D. Gordon, MD, MS – Associate Professor, Regions Emergency Medicine Residency

Abstract:

Background and Objectives: ED providers do not have clear guidelines in the use of opioids for painful conditions because there is not an effective way to determine accurate rates of patient necessity and use. Currently, provider and patient expectations about future pain guide treatment planning. We seek to establish condition-specific opioid prescribing guidelines by linking electronic health record (EHR) data from patient visits and pharmacy claims. As a step toward this goal, we sought to describe the conditions for which opioids were prescribed and the rate at which they were dispensed to adult patients discharged from the ED.

Methods: A retrospective observational cohort study was performed at our tertiary referral center examining adult patient encounters where an opioid analgesic was prescribed at ED discharge. The EHR was queried for prescription details, encounter diagnoses, and prescription claims data. Encounters with no system-driven attempt to obtain updated claims data were excluded. Principal diagnoses from all encounters were iteratively categorized into groupers and reviewed by authors until they represented optimal homogeneity. Encounters with a matching pharmacy claim for opioid prescription were marked as ‘Dispensed’ and rates of dispensing were tabulated.

Results: Over 8 months 2055 encounters had an opioid prescription and 1711 were analyzed after excluding encounters missing updates to claim data. The overall dispense rate was 42.1%. Renal conditions had the highest dispense rate (52.1%, n=211) followed by Musculoskeletal (47%, n=685), Eye (42.3%, n=26), Chest (40.9%, n=44), Abdominal (39.2%, n=237), Dental (36.6%, 71), Skin or Subcutaneous (32.6%, n= 386), Other (25.5%, n=51). In more detailed groups, Renal Stones (57.0%, n=158) and Extremity Fractures (55.6%, n=324) had the highest dispense rates.

Conclusion: Examination of ED discharge opioid prescription dispense rates by primary encounter diagnosis uncovers wide variation. Patients’ expectations of future pain may differ from their providers’ expectations, driving unfilled prescription rate differences between primary diagnoses. These data inform future work to establish optimal condition-specific opioid prescribing recommendations.

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