Initial prescription associated with long term opioid usage (via Paolo)

Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use – United States, 2006-2015.
Shah A, Hayes CJ, Martin BC.
MMWR Morb Mortal Wkly Rep.
2017 Mar 17;66(10):265-269.
doi: 10.15585/mmwr.mm6610a1.
Full text PDF:

Rothman adds:

The study has gotten some attention in the popular media as well- here’s what your patients may have read:

Ars Technica’s Beth Mole: With a 10-day supply of opioids, 1 in 5 become long-term users

Vox: The risk of a single 5-day opioid prescription, in one chart

CNN: Prescriptions may hold clues to who gets hooked on opioids, study says

Valium for acute back pain…

“….added nothing above and beyond Naproxen (which we can presume based upon very little distinction within the NSAID class is equivalent to Motrin).

In previous studies this held true for opiates as well.

So take home points—

1) Low back pain (very probably) does not need benzodiazepines
2) Low back pain (very probably) does not need opiates
3) Low back pain (most certainly) never requires an opiate/benzo combo
4) Low back pain (most likely) really only needs NSAIDs and time (probably mostly the time)
5) Don’t give more than 400mg of Motrin.”

-Dr. William Paolo

“And remember…prescribing benzodiezapines for back pain isn’t necessarily ‘safer.’ National statistics show an increase in benzodiezapine related deaths; perhaps partly attributed to their increased prescribing in response to an overall decrease in opioid prescribing.”

-Dr. Ross Sullivan

Via G. Johnson, NEJM: Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use

Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use
Michael L. Barnett, M.D., Andrew R. Olenski, B.S., and Anupam B. Jena, M.D., Ph.D.
N Engl J Med 2017; 376:663-673February 16, 2017
DOI: 10.1056/NEJMsa1610524

Increasing overuse of opioids in the United States may be driven in part by physician prescribing. However, the extent to which individual physicians vary in opioid prescribing and the implications of that variation for long-term opioid use and adverse outcomes in patients are unknown.

We performed a retrospective analysis involving Medicare beneficiaries who had an index emergency department visit in the period from 2008 through 2011 and had not received prescriptions for opioids within 6 months before that visit. After identifying the emergency physicians within a hospital who cared for the patients, we categorized the physicians as being high-intensity or low-intensity opioid prescribers according to relative quartiles of prescribing rates within the same hospital. We compared rates of long-term opioid use, defined as 6 months of days supplied, in the 12 months after a visit to the emergency department among patients treated by high-intensity or low-intensity prescribers, with adjustment for patient characteristics.

Our sample consisted of 215,678 patients who received treatment from low-intensity prescribers and 161,951 patients who received treatment from high-intensity prescribers. Patient characteristics, including diagnoses in the emergency department, were similar in the two treatment groups. Within individual hospitals, rates of opioid prescribing varied widely between low-intensity and high-intensity prescribers (7.3% vs. 24.1%). Long-term opioid use was significantly higher among patients treated by high-intensity prescribers than among patients treated by low-intensity prescribers (adjusted odds ratio, 1.30; 95% confidence interval, 1.23 to 1.37; P<0.001); these findings were consistent across multiple sensitivity analyses.

Wide variation in rates of opioid prescribing existed among physicians practicing within the same emergency department, and rates of long-term opioid use were increased among patients who had not previously received opioids and received treatment from high-intensity opioid prescribers. (Funded by the National Institutes of Health.).

Journal Club Articles, 2/1/2017

Risk of Acute Kidney Injury After Intravenous Contrast Media Administration
Hinson JS
Annals of Emergency Medicine, Article in Press
Full text via NYSL:

Is ketamine a lifesaving agent in childhood acute severe asthma?
Hendaus MA
Ther Clin Risk Manag. 2016 Feb 22;12:273-9.
Full text:

Are Antibiotics Useful for Small Skin Abscesses? (NEJM Journal Watch)

NEJM Journal Watch:
Are Antibiotics Useful for Small Skin Abscesses? Now There’s an Answer

Comments from Dr. Paolo:

Some initial thoughts on this study:

  1. Even taken at face value this is one study in a vast sea of
    literature that has found no distinction between antibiotic therapy versus
    simple incision and drainage.  If we are to assume the 7% difference in
    rate of cure as defined in the article (more to come) then difference in
    cure rate is a solitary data point that will be summated within the larger
    body of literature currently demonstrating no significant first pass cure
    rate (rates of subsequent skin and soft tissue infections aside).  This may
    move the summated needle and change the end point of the combined
    literature but it is not, in and of itself against a backdrop of negative
    studies, compelling on its own.
  2. Primary outcome was defined by a clinical test of cure assessment at
    7-14 days via a non-validated internally developed outcome measure.  This
    instrument has never been studied, externally validated, or assessed to
    determine the secondary generalizability and inter-rater reliability of the
    assessment tool.  Though the study mentions a “good inter-rater
    reliability” there is no external means to assess this instrument and it is
    the (very) subjective crux upon which the whole study rests.
  3. 34 of the total cohort was lost to follow-up and not included in an
    intention to treat analysis.  69 individuals were never assessed at the
    test of cure visit (or were excluded prior to the test of cure visit) and
    were included in the mITT-2 population.
  4. The secondary outcomes are nonsense and there are 12 of them and they
    should be dismissed out of hand and ignored.  There is no reason to include
    multiple uncontrolled, nonsensical secondary outcomes that cannot possibly
    be controlled for and will, defintionally, have significant differences
    discovered simply by the volume of the parsing of the initial dataset.
  5. The point estimate of this study offers a NNT of 14 to (and this is
    important) demonstrate clinical cure as assessed by a non-validated
    instrument at 7-10 days post incision and drainage (with no standardization
    of the I&D techniques).  This means that at best 13 people will receive no
    benefit whatsoever from the exposure to high dose antibiotics and will
    demonstrate no changes in a (non-validated) clinical assessment
    instrument.  Further if the lower bound of the confidence interval were
    true this would yield an NNT of 50 in order to achieve a benefit on the
    (non-validated) clinical assessment instrument.   There were no harms found
    in this study (NNH) to counterbalance the NNT for us to determine the
    likelihood of harm from the prescription of antimicrobials.  I am not sure
    why this occurred but we are aware of high rates of allergic reactions,
    c-diff, antimicrobial resistance, and diarrhea to counterbalance to alleged
    benefit of antimicrobial prescriptions.
  6. There were no distinctions between invasive disease between each group
    or other severe outcomes that would bias towards the treatment with
    antimicrobials.  If you believe this study and the point estimated
    difference then this study does not (as it alleges using a non-validated
    instrument) argue for treatment of all comers to the ED with initial
    antimicrobials rather than I&D alone (which cured the vast majority of
    patients)—in fact it argues that the initial treatment SHOULD be I&D alone
    followed by a return visit (or PCP follow-up) in 7-10 days for
    reassessment.  At the return visit antimicrobial therapy can be added to
    the small and select group who are deemed treatment failures rather than
    the wanton and inappropriate prescription of antibiotics to all comers
    (based upon this study and its non-validated clinical assessment