For nearly two years, we have understandably had our focus on mitigating the effects of the COVID-19 pandemic and less attention has been given to the worsening epidemic of opioid misuse and the associated rise in deaths. While the majority of deaths have occurred among adults, a notable percentage of people dealing with opioid misuse first used opioids prior to adulthood. For many children, the first opioid exposure follows an emergency department (ED) visit for a fracture. It should be noted that approximately 80% of current heroin users first started with prescription opioids suggesting that physicians have played a role in the current epidemic.1
Fortunately, there have been efforts to train physicians on proper opioid prescribing. Unfortunately, scant attention is being focused on providing such training as it pertains to pediatric populations. That is why this article by Shenoi et al (10.1542/peds.2020-039743) is so important as they demonstrate a way to effectively address the “silent epidemic” of opioid misuse that can begin in the emergency department.
Shenoi et al implemented a quality improvement project in a pediatric ED in two Plan-Do-Study-Act cycles over the course of two years that significantly reduced overall opioid prescriptions written for patients with closed fractures and drained abscesses. The secondary outcomes of statistical significance included reducing prolonged (>3 days) opioid prescriptions, improving the opioid anticipatory guidance given to families, and increased physician enrollment in the state’s prescription drug monitoring program. Most importantly, these outcomes were observed without increasing the percentage of patients who had uncontrolled pain.
It should be noted that only attendings can prescribe opioids in the ED profiled in this study and the authors correctly note that prolonged opioid prescriptions are more likely to be written by resident trainees. This suggests that there is more work to be done to ensure that all medical interns/residents receive opioid prescribing education for all patients, especially children.
While the authors admit that they do not know whether a patient followed up at a different location to get more pain medications, the findings are a notable first-step in demonstrating a proof of concept for a scalable approach for secondary prevention of opioid misuse among our colleagues who are often on the “front lines” of pain management for our opioid naïve patients. Such an approach is important to addressing the present-day morass of the opioid epidemic while being mindful of the need to implement primary preventive approaches including providing evidence-based opioid prescribing education to medical trainees.
- Muhuri PK, Gfroerer JC, Davies MC. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. CBHSQ Data Rev. August 2013.