Opioids Linked to More Return Visits After Emergency Pain Treatment

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Using opioids to treat acute pain in the emergency room led to more unplanned healthcare visits compared with using intranasal nonsteroidal anti-inflammatory drugs (NSAIDs). The difference was predominantly caused by worse pain control and more medication side effects in the opioid group.

Although opioid prescriptions have declined in the United States from 21.5% in 2011 to 8.1% in 2019 among patients discharged from the emergency room, investigators say this rate remains relatively high. Plus, reductions in opioid prescriptions have not been matched by increases in nonopioid prescriptions, such as NSAIDs. This may be due in part to concerns about side effects, although previous research has shown patients taking NSAIDs do not experience higher rates of serious adverse events. Conversely, opioids are linked to a variety of adverse outcomes, including opioid use disorder and even death.

“Recent data suggest opioid prescriptions in the outpatient setting are associated with an increased number of subsequent healthcare visits,” wrote a team of investigators led by Caroline E. Freiermuth, M.D., associated with the Department of Emergency Medicine and the Center for Addiction Research at the University of Cincinnati College of Medicine. “Unplanned visits can result in missed days of work, disrupting the daily lives of patients, as well as increased costs, often higher with the repeat than the initial emergency [room] visit.… Emergency physicians must understand how the treatment they provide in the emergency [room] may affect downstream healthcare utilization to fully consider the impact of their care on both patients and healthcare systems.”

When treating pain, clinicians aim to manage the symptoms while reducing potential side effects and preventing the need for follow-up visits. In the current study, investigators evaluated whether the type of pain treatment (opioids, intranasal NSAIDs or a combination) impacted the chances of patients requiring unplanned healthcare visits following an emergency room discharge. To do so, they used data from the prospective, observational Acute Management of Pain from the Emergency Department (AMPED) study, which tracked patients with acute pain after emergency room visits. They analyzed how quickly patients returned for unplanned healthcare visits, depending on the pain treatment they received. They also investigated whether ongoing pain or medication side effects influenced these visits.

Out of 831 patients analyzed, 141 (17%) had an unplanned healthcare visit within five days of discharge, mostly occurring the day after the initial visit. Patients treated only with intranasal NSAIDs, such as ketorolac, were less likely to return for an unscheduled visit than those treated with opioids.

Patients treated with opioids had higher levels of pain and more side effects, which increased their likelihood of needing follow-up care. Side effects and pain levels explained much of the increased return visits in the opioid group.

Investigators noted that as this was a secondary analysis of observational data, every possible confounder could not be measured or controlled for. Additionally, results may be susceptible to selection bias, as the study was not randomized. Another limitation was that data were collected between 2012 and 2014, and pain treatment regimens have evolved since then. This may have hindered the applicability of results.

“Understanding the impact that pain medication choice has on recurrent healthcare utilization and the factors that mediate this relationship adds to the body of knowledge regarding risks and benefits of these treatments, allowing emergency physicians to make better informed decisions,” investigators concluded.