Opioid Deprescribing in Emergency Medicine—A Tool in an Expanding Toolkit

The opioid crisis has been a top public health priority for more than a decade. Although its latest evolution involves epidemic-level deaths from illicitly manufactured fentanyl and its analogues, the origin of the crisis can be definitively traced to the overprescribing of prescription opioids. Although broad-based efforts across all specialties have resulted in substantial reductions in opioid prescribing, the study by Smith et al1 demonstrates that efforts in their emergency department (ED) outpaced any secular trend. Their study evaluated opioid prescribing in an urban, academic ED and found a 66.3% decline between 2013 and 2018 for a variety of painful conditions, a rate substantially greater than those reported in previous studies and in national data. When initial reports about opioid overprescribing emerged, government-derived data highlighted emergency medicine as a top-prescribing specialty based on the number of prescriptions written. However, later work demonstrated that, despite evaluating and treating substantial numbers of patients with pain, ED opioid prescriptions were typically for small quantities (eg, a mean of 17 tablets),2 highlighting that, even in earlier eras, emergency physicians were reticent to prescribe opioids for more than a few days. Although ED prescribing has not been the primary driver of the epidemic of opioid use disorder (OUD), hyperalgesia, overdose, and death associated with prescription and illicit opioids, there remain opportunities for improvement. Perhaps because Smith et al1 are not emergency physicians, the process leading to their institution’s success is not described in detail. It is worthwhile to highlight that the specialty of emergency medicine has addressed analgesia and its consequences and that many of these efforts generalize to other clinical departments and across the health care continuum. Emergency departments function as 24/7 pain safety nets for those with a range of acute and chronic pain syndromes, including patients at the end of life from cancer or those experiencing complex pain, such as vaso-occlusive crises. Through the development of various (ie, institutional, state-based, specialty-wide, and national) guidelines, emergency physicians have been on the forefront of focused efforts to reduce opioid use while balancing the needs of individual patients with the sanctity of the public health. Unquestionably, the answer is not simply to stop prescribing opioids but rather to look critically at our practices and evaluate opportunities to improve. As likely is operative in the study by Smith et al,1 ED analgesia guidelines have evolved from limiting indications for opioids in common conditions, such as headache and abdominal pain, to the current emphasis on the particulars of what is prescribed, to whom, and for what duration. It is important to note that Smith et al1 found the largest reduction in opioid prescribing for musculoskeletal pain, for which alternative medications, such as nonsteroidal anti-inflammatory drugs, have demonstrated superiority to opioids.3 They identified less benefit for conditions such as ureterolithiasis for which there was not a clearly superior opioid alternative. Although there are no adequate risk prediction tools to help to identify individual factors associated with developing consequential opioid use, there is an indisputable fact: long-term opioid use cannot develop without exposure to an opioid. Therefore, as in the study by Smith et al,1 more attention needed (and still needs) to focus on avoiding unnecessary opioid exposure. Interestingly and supportive of current trends, data support that the duration of the initial opioid prescription may best predict adverse outcomes,4 and this finding has been robust across the spectrum of medical and surgical pain care. New-era pain management guidelines typically recommend nonopioids or even nonpharmaceutical options to initially address pain, relegating the use of opioids to third-line agents + Related article