Prescription opioid use in general and pediatric emergency departments
Menchine M, Lam CN, Arora S. Pediatrics. 2019;144(5):e20190302.
SUMMARY:
For years, pain in children has been documented to be undertreated, but exposure to prescribed opioids is now being understood to be associated with future misuse.
Generally, emergency medical care of pediatric patients occurs in 2 relatively distinct practice environments: general EDs, which provide care for adults and children and are staffed by general emergency physicians, and pediatric EDs, which are located in children’s hospitals and are typically staffed by pediatric emergency-medicine-trained physicians.
Pediatric EDs are often considered to set the standard of care for treating children, but whether the administration of opioid and/or nonopioid analgesics is handled differently across practice environments is currently unknown.
We conducted a secondary analysis of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2006 to 2015. The outcomes of interest were (1) whether an opioid was given in the ED, (2) whether an opioid prescription was given at discharge, or (3) whether a nonopioid analgesic prescription was given at discharge.
From NHAMCS, children, adolescents, and young adults (<25 years of age) accounted for 111,219 records corresponding to 474,989,623 ED visits.
After adjustment for age, mode of arrival, pain severity, race and/or ethnicity, and insurance, the odds of being administered an opioid were similar for children, adolescents, and young-adult patients treated in a pediatric versus general ED (OR 0.88).
We also investigated patients with fractures (a group that would generally tend to receive an opioid) and again found that the chance of receiving an opioid was similar in general versus pediatric EDs (OR 1.10).
Regarding prescriptions, after adjustment for the aforementioned variables, children were much less likely to be sent home with an opioid when treated in a pediatric ED than a general ED (OR 0.37). In the fracture-only subset, 39.1% of children treated in general EDs received an opioid prescription, compared with just 11.9% of those treated in pediatric EDs.
This study has some limitations: (1) there are no doses in NHAMCS, so although the chance of receiving an opioid in the ED is known to be the same, any potential differences in morphine equivalents are unknown, and (2) we needed to develop our own method to choose pediatric EDs from the data.
EDITOR’S COMMENTARY: In this large national database study, we found that although children, adolescents, and young adults had similar odds of being administered opioids while in the ED, they had markedly lower odds of receiving an outpatient opioid prescription at discharge from a pediatric ED than a general ED, even when the analysis was restricted to patients with fracture. Although we can’t explain why this huge difference exists or which practice pattern is right, my gut feeling is that the answer lies somewhere in the middle, meaning we can all change a bit.
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