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Paper Chase 2- Downstream Effects of ED Opioid Prescriptions

Sanjay Arora, MD and Mike Menchine, MD
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06:07
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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN
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01:06

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EM:RAP 2017 June Written Summary 647 KB - PDF

Patients exposed to a high-intensity opioid prescriber in the ED were 30% more likely to engage in long-term opioid use compared to similar patients who were treated by lower intensity opioid prescribers.

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Mark M., MD -

I thought the message in this segment was ambivalent. You use a relative percentage of 30% more chronic use among high intensity prescribers making ED responsibility in opioid problems sound bad and conclude that we should be McStingy with opioids in the ED.
But the science you presented (and the science that exists) shows that the ED plays very little role in opioid deaths, non-medical use of opioids, prescription opioids for chronic pain, as well as prescription opioids for acute pain leading to chronic use (1.2% in low prescribers and 1.5% in high prescribers--absolute difference of 0.3%). You also failed to mention that the very small percentage of patients who do go on to chronic use are characterized by previous substance abuse and/or psychiatric illness. All the science suggests that even if we were all McStingy we would have little impact on changing anything other than decrease the one thing we do best--acute pain management! We shouldn't be McStingy with opioids. We should just be McCareful.

Would like to add one quote and one reference:
"The reality however is that most patients receiving an initial opioid prescription do not proceed to chronic use (98-99%) and among the subset that do use long-term opioids, the majority neither misuse or experience an overdose. An unintended consequence of excessive concerns raised about opioids could be an increasing reluctance among clinicians to prescribe even small amounts of opioids for a limited time for acute pain, including the patients discharged from the emergency department..."
-Kroenke K. et al. JAMA May 11, 2017

Also see Kertesz et al. Substance Abuse 2017;38:3-8.

*love EMrap (first time to write in for dialogue)

Jeremy V. -

Why don't they give more info about the "high intensity providers"?

I can't see the connection between frequency of prescriptions written to a cohort of patients and the likelihood of a single patient having increased risk of chronic use.

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Don’t Fear The Stink! Full episode audio for MD edition 245:23 min - 342 MB - M4AEM:RAP 2017 June Canadian Edition Canadian 24:49 min - 34 MB - MP3EM:RAP 2017 June German Edition Deutsche 68:28 min - 94 MB - MP3EM:RAP 2017 June French Français 29:35 min - 41 MB - MP3EMRAP 2017 June Resumen Español Español 94:49 min - 130 MB - MP3EM:RAP 2017 June Board Review Answers 187 KB - PDFEM:RAP 2017 June Board Review Questions 170 KB - PDFEM:RAP 2017 June MP3 328 MB - ZIPEM:RAP 2017 June Written Summary 647 KB - PDF

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