Patient-reported opioid pill consumption after an ED visit: how many pills are people using?
McCarthy DM, Kim HS, Hur SI, et al. Pain Med. 2021;22(2):292-302.
Numerous strategies at the state and national levels are aimed at minimizing the amounts of opioid pills prescribed in the ED, including formal prescribing limits; the CDC has recommended that a 3-day supply should generally be sufficient, and a supply for more than 7 days is rarely needed.
But what is a 3-day supply? It is possible someone might take a Norco every 4 hours, for a total of 18 pills, or just a few pills on the first few days, for a total of 3 or 4 pills?
Here, the authors present data on a subanalysis of a larger trial focused on the safe use and disposal of opioids, in which adult ED patients who were given a prescription for hydrocodone-acetaminophen and were not chronic opioid users were asked to keep a medication diary including prescription and over-the-counter medications.
Of 652 patients enrolled, only 260 patients returned medication diaries; of those, 57.1% were women, and the mean age was 46.
The participants who returned medication diaries differed significantly from the overall sample enrolled: they were older; had higher educational attainment, literacy, and household earnings; and were less likely to be uninsured or to belong to a racial/ethnic minority group.
The indications included back pain (17.3%), renal colic (20%), fracture/dislocation (20.8%), other musculoskeletal injury (15.4%), and other diagnosis (26.5%).
The median quantity of pills given was 12 (90 morphine milligram equivalents [MME]), but the quantity varied by diagnosis: patients with renal colic received the most (14.5 pills and 120 MME), and patients with musculoskeletal injuries received the least (60 MME).
For all diagnoses combined, the median number of pills taken was 10, but this amount also varied by diagnosis: patients with renal colic took the least (3 pills), and patients with back pain took the most (12 pills).
Most patients with renal colic also stopped taking opioids by day 2, whereas the rest of the groups decreased their use more gradually over the 10-day study period. Regardless of the diagnosis or postdischarge day, the number of pills consumed on a given day was typically 1 or 2.
Interestingly, NSAID use patterns followed a similar trajectory to opioid use rather than showing a replacement or substitution effect over time.
Finally, 93% of patients reported having leftover opioid pills even at these low initial quantities.
The largest limitation in this study is that less than half of the sample returned the medication diaries, and the group that did not return them was different in potentially important ways.
EDITOR’S COMMENTARY: In this single-site observational study of ED patients who received prescription opioids, most patients used only 1-2 pills a day, and patients with renal colic used much fewer total pills than everyone else. It is hard to make a one-size-fits all approach to pain management, but aiming for the expected duration of pain rather than the severity may be helpful. The concern about leftover pills and potential diversion is a more difficult one to address, but education on safe disposal could potentially mitigate this problem.
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