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Patterns of Prescription Opioid Use in Swiss Emergency Department Patients and Its Association with Outcome: a Retrospective Analysis

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Patterns of Prescription Opioid Use in Swiss Emergency Department Patients and Its Association with Outcome: a Retrospective Analysis Open access Original research BMJ Open: first published as 10.1136/bmjopen-2020-038079 on 25 September 2020. Downloaded from Patterns of prescription opioid use in Swiss emergency department patients and its association with outcome: a retrospective analysis Bertram K Woitok ,1 Petra Büttiker,1 Svenja Ravioli,1 Georg- Christian Funk,2 Aristomenis K Exadaktylos,3 Gregor Lindner1 To cite: Woitok BK, Büttiker P, ABSTRACT Strengths and limitations of this study Ravioli S, et al. Patterns of Objectives We aimed to clarify the prevalence, prescription opioid use in indications, analgesic comedications and complications ► The large data set provides high power. Swiss emergency department of prescription opioid use in patients presenting to a large patients and its association ► First European data on individual dosages and indi- emergency department (ED). with outcome: a retrospective cations of prescription opioids. Design Retrospective chart review. analysis. BMJ Open ► Potential significant selection bias due to missing Setting Large, interdisciplinary ED of a public hospital. 2020;10:e038079. doi:10.1136/ medication data. bmjopen-2020-038079 Participants All patients aged ≥18 years presenting ► Single- centre study; therefore, the results are not between 1 January 2017, and 31 December 2018, with necessarily generalisable. ► Prepublication history for documentation on medication were included. this paper is available online. Interventions None. To view these files, please visit the journal online (http:// dx. doi. Primary and secondary outcome measures Prevalence org/ 10. 1136/ bmjopen- 2020- rates for prescription opioid use and its indication. dependency, misuse of dispensed drugs and 038079). Prevalence of analgesic comedications in prescription adverse events. Although short-term use opioid users. Hospitalisation rate, 72 hours ED seems to be unlikely to cause dependency,2 Received 27 February 2020 reconsultation rate, 30- day rehospitalisation rate, in- Revised 23 August 2020 hospital mortality. there is evidence that opioid prescriptions Accepted 24 August 2020 Results A total of 26 224 consultations were included in the emergency department (ED) can lead 3–5 in the analysis; 1906 (7.3%) patients had prescriptions to dependency in susceptible patients. http://bmjopen.bmj.com/ for opioids on admission to the ED. The main indications Considering the recent increased prevalence for opioid prescriptions were musculoskeletal disease in of prescription opioid analgesics in the USA, 1145 (60.1%) patients, followed by neoplastic disease opioid misuse is a major concern.6 In Europe, in 374 (19.6%) patients. One hundred fifty- four (8.2%) prescription opioids are increasingly used, consultations were directly related to opioid intake, and but with 8967 defined daily doses (DDD) per 50.1% of patients on opioids also used other classes of million inhabitants in Europe (11 850 for analgesics. Patients on prescription opioids were older (76 Switzerland) compared with 16 491 DDD in vs 62 years, p<0.0001) and female individuals were over- the USA in 2016, their prevalence is lower in © Author(s) (or their represented (58 vs 48.9%, p<0.0001). Hospitalisation rate 7 on September 26, 2021 by guest. Protected copyright. employer(s)) 2020. Re- use (78.3 vs 49%, p<0.0001), 72 hours ED reconsultation rate Europe than the USA. Data on prescription permitted under CC BY-NC. No (0.8 vs 0.3%, p=0.004), 30- day rehospitalisation rate (6.2 opioid misuse in Europe are scarce. Kalkman commercial re- use. See rights vs 1.5%, p<0.0001) and in- hospital mortality (6.3 vs 1.6%, et al studied opioid misuse in the Nether- and permissions. Published by p<0.0001) were significantly higher in patients with opioid lands and found a prevalence of 5.6 per BMJ. therapy than other patients. In 25 cases (1.3%), admission 8 1 100 000 inhabitants in 2015, whereas data Department of Internal to the ED was due to opioid intoxication. and Emergency Medicine, from the USA showed a prevalence of 22.1 Conclusions Daily prescription opioid use is common 9 Bürgerspital Solothurn, per 100 000 inhabitants in 2013. In Canada, in patients presenting to the ED. The use of prescription Solothurn, Switzerland opioid overdosing increased in the past 10 2 opioids is associated with adverse outcomes, whereas Karl- Landsteiner- Institute for years, reaching 15.6 per 100 000 in 2016– intoxication is a minor issue in the studied population. Lung Research and Pulmonary 2017.10 The differences between Europe and Oncology, Wilhelminenspital, Vienna, Austria the USA are especially pronounced when 3Department of Emergency INTRODUCTION comparing opioid- related deaths; although in Medicine, Inselspital Bern, Bern, Opioids are widely used in ambulatory and Europe, deaths were stable at approximately Switzerland hospitalised patients, but there is concern 1.2 per 100 000 inhabitants per year in 2007 Correspondence to regarding their liberal prescription before and 2016, there were 15 deaths per 100 000 Dr Bertram K Woitok; alternative approaches have proven ineffec- inhabitants from opioid overdose in the USA bertram. woitok@ spital. so. ch tive.1 The three major concerns are: creating in 2017.8 Woitok BK, et al. BMJ Open 2020;10:e038079. doi:10.1136/bmjopen-2020-038079 1 Open access BMJ Open: first published as 10.1136/bmjopen-2020-038079 on 25 September 2020. Downloaded from Physicians are also confronted with other downsides scientific purposes written or verbally were excluded from of opioid use. Adverse events such as nausea, vertigo and the analysis. constipation have been widely reported. Moreover, it has been shown that patients undergoing opioid therapy have Measurements significantly decreased cognitive function as measured by Demographic data were gathered from all included the Mini- Mental State Examination and Montreal Cogni- patients on comorbidities, current medication, indi- tive Assessment.11 In addition, it has been found that cations for opioid prescriptions, reason for current patients presenting with vertigo, who were also prescribed ED consultation and relation to opioid intake, need to opioids, were at significantly higher risk of fractures than administer naloxone, need for hospitalisation, 72-hour patients who were not prescribed opioids.12 The inci- ED reconsultation, hospital length of stay, mortality, pres- dence of adverse events from opioids prescribed in the ence of alcohol and/or benzodiazepine cointoxication in ED is generally low and associated with age, sex and route patients taking opioid analgesics presenting with opioid- of administration.13 Another point to consider is the accu- intoxication and estimated glomerular filtration rate mulation of opioid- metabolites in patients with impaired (GFR) by the CKD-EPI- Formula. Indications for opioid renal function. Hydromorphone is considered a safer prescriptions were either categorised as ‘neoplastic treatment than morphine and oxycodone.14 disease’, ‘musculoskeletal’ (which comprised degenera- Most available data on prescription opioid use are from tive, traumatic and autoimmune diseases of the locomotor the USA, where the lay press, experts and even govern- system) or ‘other’. The outcomes ‘constipation’, ‘vertigo’, ment officials are talking about a national crisis due to ‘delirium’, ‘pain’, ‘opioid intoxication’ and ‘presentation opioid overuse. Although little data are available from due to opioid therapy’ were flagged if stated as such in the central Europe, it is likely that there are considerable discharge report. Data on the duration of opioid therapy national discrepancies in the patterns of opioid use. To and the actual usage of on- demand prescriptions were the best of our knowledge, no single study on the prev- not consistently available and thus were not analysed. alence of prescription opioid use and its indications and Chart reviews and data extraction were performed by association with the outcome from a large heterogenic the same three persons (BW, PB, SR), who are all trained patient collective with data from central Europe exists. medical professionals. The criteria for abstraction were Therefore, we aimed to evaluate: (1) the prevalence of predefined and explained in detail to the researchers. All outpatient prescription opioid use and analgesic come- cases that could not be classified clearly with the initial dication in opioid users. Furthermore, we investigated criteria were marked as ‘unclear’ and reviewed by the (2) the indications and (3) the association with adverse same person (BW). Apart from that, no monitoring of outcomes of prescription opioid use in a large, hetero- the chart abstraction was performed. We did not assess genic collective of patients presenting to the ED of a large interobserver reliability. Data were stored in a central public hospital. database in an anonymised fashion. http://bmjopen.bmj.com/ Statistical methods METHODS Out of 1923 dosages of opioids, 94 (4,9%) were missing Study design and setting and imputed from the median doses of the respective The Department of Emergency Medicine of the Bürg- opioid. In 6737 patients (25.7%), a GFR >90 was imputed erspital Solothurn is an interdisciplinary ED, treating from a normally distributed value between 91 and 130. approximately 35 000 patients per year. We performed After completion of data collection, data were cleaned a retrospective chart review of all admissions to our ED and outliers (>95% CI) were reconfirmed or corrected. on September 26, 2021 by guest. 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