Children, adolescents, and young adults treated in pediatric emergency departments (EDs)—departments associated with children’s hospitals—are much less likely to be prescribed opioids compared to patients of similar age and ailment treated at general EDs. This is according to a new study by researchers at the USC Schaeffer Center for Health Policy & Economics and Keck School of Medicine of USC and published this week in Pediatrics. The study is a significant contribution to our understanding of opioid prescribing patterns in pediatric patients.
“We found that young people seen in a general ED are three times more likely to be given an opioid prescription compared with similar young people treated in pediatric EDs,” said Michael Menchine, an associate professor of clinical emergency medicine at Keck School of Medicine of USC. “Most patients- whether young or old- who come into the emergency room are experiencing some kind of pain. This is an important finding as we think about the role and best practices of emergency departments in managing that pain while reevaluating how opioids are used.” Menchine is also a clinical fellow at the Schaeffer Center.
Emergency Care and Pain Management for Young People
Emergency medical care for pediatric patients occurs in two distinct settings: general emergency departments which provide care for adults and children and are staffed by general emergency physicians and pediatric EDs which are located in children’s hospitals and are typically staffed by pediatric emergency physicians. While pediatric EDs are generally looked to for best practices, the large majority of pediatric emergency patients are still treated in the general ED setting.
Young people have not been shielded from the national opioid crisis: Since the 1990s, children, adolescents, and young adults have also experienced dramatic increases in exposure to and harms from prescription opioids.
While recent research has shown a link between exposure to prescribed opioids in the emergency room and future opioid misuse among young people, the CDC guidelines for opioid treatment are specifically for adults. In fact, the CDC guidelines explicitly exclude children because of the lack of an evidence-base for prescribing standards. Furthermore, some pediatric pain experts have warned of potential serious negative consequences of applying the adult guidelines to the younger population. Identifying disparities between pediatric and general EDs provides opportunities for the development of best practices in emergency care and pain management for young patients.
Opioid Prescribing Varies Between Pediatric and General Emergency Departments
Menchine and his colleagues analyzed a large nationally representative data set of ED visits from 2006-2015 compiled by the Centers for Disease Control and Prevention (CDC) to assess whether or not the hospital setting was associated with differences in prescribing patterns. They defined a pediatric ED as one in which the average age of patients treated was under 18 and less than 10 percent of visits were from patients over age 25. In their data set, 9 out of 10 young persons were treated in general EDs.
The researchers found that after adjusting for age, mode of arrival, pain severity, race/ethnicity, and insurance, patients seen in pediatric EDs were significantly less likely to be prescribed opioid medications at discharge. While 10.9 percent of visits to general EDs resulted in an opioid prescription at discharge, only 1.6 percent of visits at pediatric EDs did. Patients at pediatric EDs were more likely to receive a prescription for a non-opioid painkiller.
The researchers also looked specifically at young adults and children who came into the emergency room with a fracture or dislocation. They found 39.1 percent of those treated in general EDs received an opioid prescription at discharge compared with just 11.9 percent of those treated in pediatric EDs.
Extrapolating out, the researchers estimate that if general EDs had employed a similar prescribing pattern as pediatric EDs, 28 million fewer opioid prescriptions would have been given to children, adolescents and young adults over the study period.
“We would like to believe that the decision of whether or not to prescribe a patient an opioid would be largely driven by the patient’s condition. However, these findings highlight how the culture of the particular environment are huge drivers of prescribing,” explained Menchine. “It seems like the general habit of high levels of opioid prescribing to adults simply trickles down to children and adolescents when they are treated in general EDs.”
Menchine and his colleagues point out that adult ED patients report significantly higher levels of severe pain and have more chronic painful conditions which may lead to expecting or demanding higher rates of opioid prescribing. General ED providers may therefore have a higher set-point, whether intentional or not, that may influence prescribing for adults and children.
Given adolescents’ vulnerability to drugs due to their changing brain chemistry, as well as the nation’s opioid crisis, understanding why the disparity in prescribing occurs is an important next step in the research.
In addition to Menchine, Sanjay Arora and Chun Nok Lam, both affiliated with Keck School of Medicine of USC, co-authored the study. The study was funded through the Department of Emergency Medicine at Keck School of Medicine of USC.