Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: Despite treatment guidelines suggesting alternatives, as well as evidence of a lackof benefit and evidence of poor long-term outcomes, opioid analgesics are commonly prescribedfor back pain from the emergency department (ED). Variability in opioid prescribing suggests a lackof consensus and an opportunity to standardize and improve care. We evaluated the variation inattending emergency physician (EP) opioid prescribing for patients with uncomplicated, low acuityback pain (LABP).

Methods: This retrospective study evaluated the provider-specific proportion of LABP patientsdischarged from an urban academic ED over a seven-month period with a prescription for opioids.LABP was strictly defined as (1) back pain chief complaint, (2) discharged from ED with nointerventions, and (3) predefined discharge diagnosis of back pain. We excluded providers if theyhad less than 25 LABP patients in the study period. The primary outcome was the physician-specificproportion of LABP patients discharged with an opioid analgesic prescription. We performed adescriptive analysis and then risk standardized prescribing proportion by adjusting for patient andclinical characteristics using hierarchical logistic regression.

Results: During the seven-month study period, 23 EPs treated and discharged at least 25 LABPpatients and were included. Eight (34.8%) were female, and six (26.1%) were junior attendings (< 5years after residency graduation). There were 943 LABP patients included in the analysis. Providerspecificproportions ranged from 3.7% to 88.1% (mean 58.4% [SD +/- 22.2]), and we found a 22-foldvariation in prescribing proportions. There was a six-fold variation in the adjusted, risk-standardizedprescribing proportion with a range from 12.0% to 78.2% [mean 50.4% (SD +/-16.4)].

Conclusion: We found large variability in opioid prescribing practices for LABP that persistedafter adjustment for patient and clinical characteristics. Our findings support the need to furtherstandardize and improve adherence to treatment guidelines and evidence suggesting alternatives toopioids.