Trends in and predictors of hydromorphone administration in US emergency departments (2007-2014)

Maryann Mazer-Amirshahi, PharmD, MD, MPH; Diana Ladkany, MD; Peter M. Mullins, MA, MPH; Sergey Motov, MD; Jeanmarie Perrone, MD; Lewis S. Nelson, MD; Jesse M. Pines, MD, MBA, MSCE

doi:10.5055/jom.2018.0458

Authors

Maryann Mazer-Amirshahi, PharmD, MD, MPH
Diana Ladkany, MD
Peter M. Mullins, MA, MPH
Sergey Motov, MD
Jeanmarie Perrone, MD
Lewis S. Nelson, MD
Jesse M. Pines, MD, MBA, MSCE

DOI:

https://doi.org/10.5055/jom.2018.0458

Keywords:

hydromorphone, administration, emergency department

Abstract

Objective: To examine recent trends in and predictors of hydromorphone administration in US emergency departments (EDs) compared with other opioids.

Design: Retrospective review of data from the National Hospital Ambulatory Medical Care Survey from 2007 to 2014.

Participants: All adult ED visits where an opioid analgesic was administered were included.

Main outcome measures: Trends in and predictors of hydromorphone administration were assessed using survey-weighted logistic regression, comparing hydromorphone visits with ED visits where other opioids were administered.

Results: From 2007 to 2014, in an estimated 128.9 million US ED visits where opioids were administered, hydromorphone use increased significantly from 30.2 percent in 2007 to 36.8 percent of visits in 2014 (p = 0.027). Hydromorphone accounted for a greater proportion of opioids administered by the end of the study period, compared to other opioids. Patient characteristics associated with hydromorphone were age <65 years, white race, private insurance or Medicare, and severe pain. Patients who received hydromorphone also had indicators of higher severity illness, including more laboratory testing, procedures, and higher admission rates. Common conditions where hydromorphone was administered were headache, back pain, musculoskeletal pain, and abdominal pain.

Conclusion: From 2007 to 2014, hydromorphone was administered to more than one in three US ED patients who were administered opioids, and several factors predicted its use. High use was found in some conditions where opioid use is inappropriate, suggesting a need for additional initiatives to promote rational prescribing of high-potency opioids.

Author Biographies

Maryann Mazer-Amirshahi, PharmD, MD, MPH

Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC; The Georgetown University School of Medicine, Washington, DC

Diana Ladkany, MD

Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC

Peter M. Mullins, MA, MPH

The George Washington University School of Medicine and Health Sciences, Washington, DC

Sergey Motov, MD

Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York

Jeanmarie Perrone, MD

Department of Emergency Medicine, Perleman School of Medicine, Philadelphia, Pennsylvania

Lewis S. Nelson, MD

Department of Emergency Medicine, Rutgers New Jersey School of Medicine, Newark, New Jersey

Jesse M. Pines, MD, MBA, MSCE

Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC

References

Mazer-Amirshahi M, Mullins PM, Rasooly I, et al.: Rising opioid prescribing in adult U.S. emergency department visits: 2001-2010. Acad Emerg Med. 2014; 21(3): 236-243.

Mazer-Amirshahi M, Dewey K, Mullins PM, et al.: Trends in opioid analgesic use for headaches in U.S. emergency departments. Am J Emerg Med. 2014; 32(9): 1068-1073.

Mazer-Amirshahi M, Mullins PM, Rasooly IR, et al.: Trends in prescription opioid use in pediatric emergency departments. Pediatr Emerg Care. 2014; 30(4): 230-235.

Manchikanti L, Helm S 2nd, Fellows B, et al.: Opioid epidemic in the United States. Pain Physician. 2012; 15(3 Suppl): ES9-E38.

Maxwell JC: The prescription drug epidemic in the United States: A perfect storm. Drug Alcohol Rev. 2011; 30(3): 264-270.

Centers for Disease Control and Prevention: Prescription opioid overdose data. Available at http://www.cdc.gov/drugoverdose/data/overdose.html. Accessed August 6, 2016.

Gulseth MP, Meisel S, Meisel M: Increasing the safety of analgesia use in a community hospital. Am J Health Syst Pharm. 2004; 61(11): 1143-1146.

Odera GM, Said Q, Evans RS, et al.: Opioid-related adverse drug events in surgical hospitalizations: Impact on costs and length of stay. Ann Pharmacother. 2007; 41(3): 400-406.

Neil K, Marcil A, Kosar L, et al.: Retrospective analysis of opioid medication incidents requiring the administration of naloxone. Can J Hosp Pharm. 2013; 66(5): 280-288.

Beaudoin FL, Merchant RC, Janicki A, et al.: Preventing iatrogenic overdose: A review of in-emergency department opioid-related adverse drug events and medication errors. Ann Emerg Med. 2015; 65(4): 423-431.

Butler MM, Ancona RM, Beauchamp GA, et al.: Emergency department prescription opioids as an initial exposure preceding addiction. Ann Emerg Med. 2016; 68(2): 202-208.

Kea B, Fu R, Lowe RA, et al.: Interpreting the National Hospital Ambulatory Medical Care Survey: United States emergency department opioid prescribing, 2006-10. Acad Emerg Med. 2016; 23(2): 159-165.

Knotkova H, Fine PG, Portenoy RK: Opioid rotation: The science and the limitations of the equianalgesic dose table. J Pain Symptoms Manage. 2009; 38(3): 426-439.

Vallner JJ, Stweart JT, Kotzan JA, et al.: Pharmacokinetics and bioavailability of hydromorphone following intravenous and oral administration to human subjects. J Clin Pharmacol. 1981; 214(4): 152-156.

Sutter ME, Wintemute GJ, Clarke SO, et al.: The changing use of intravenous opioids in an emergency department. West J Emerg Med. 2015; 16(7): 1079-1083.

Chang AK, Bijur PE, Meyer RH, et al.: Safety and efficacy of hydromorphone as an analgesic alternative to morphine in acute pain: A randomized clinical trial. Ann Emerg Med. 2006; 48(2): 164-172.

Chang AK, Bijur PE, Napolitano A, et al.: Two milligrams i.v. hydromorphone is efficacious for treating pain but is associated with oxygen desaturation. J Opioid Manag. 2009; 5(2): 75-80.

Cantrill SV, Brown MD, Carlisle RJ, et al.: Clinical policy: Critical issues in the prescribing of opioids for adult patients in the emergency department. Ann Emerg Med. 2012; 60(4): 499-525.

Food and Drug Administration: Draft blueprint for prescriber education for long-acting/extended-release opioid classwide risk evaluation and mitigation strategy (76 FR 68766) 2011. Federal Register Volume 76, Issue 215.

New York State Department of Health: New York's Medical Conduct Program. Pain management: A guide for physicians. Available at http://www.painpolicy.wisc.edu/sites/default/files/sites/www.painpolicy.wisc.edu/files/4179.pdf. Accessed July 10, 2018.

Neve DE, Sabel JC, Howell DN, et al.: The development of the Washington State emergency department opioid prescribing guidelines. J Med Toxicol. 2012; 8(4): 353-359.

Bickel WK, Bigelow GE, Preston KL, et al.: Opioid drug discrimination in humans: Stability, specificity and relation to self-reported drug effect. J Pharmacol Exp Ther. 1989; 251(3): 1053-1063.

Brush DE: Complications of long-term opioid therapy for management of chronic cain: The paradox of opioid-induced hyperalgesia. J Med Toxicol. 2012; 8(4): 387-392.

Sosnowski MA: Review article: Lack of effect of opiates in the treatment of acute cardiogenic pulmonary oedema. Emerg Med Australas. 2008; 20(5): 384-390.

Silberstein SD: Standards subcommittee of the American Academy of Neurology Headache (an evidence-based review): Report of the quality practice parameter: Evidence-based guidelines for migraine. Neurology. 2000; 55(6): 754-762.

Tepper S: Medication-overuse headache. Continuum. 2012; 18(4): 807-822.

Qaseem A, Wilt TJ, McLean RM, et al.: Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017; 166(7): 514-530.

Paice JA, Gordon D: Safe use of opioids in hospitals. The Joint Commission: Sentinal Event Alert. 2012; 8(49): 1-5.

Paparella S: Intravenous hydromorphone: Can you manage the risk. J Emerg Nurs. 2011; 37(4): 377-380.

Dilaudid-HP [package insert]: Prescribing information. Available at https://www.drugs.com/dosage/dilaudid-hp.html. Accessed September 20, 2016.

Centers for Disease Control and Prevention: Ambulatory health care data. http://www.cdc.gov/nchs/ahcd/about_ahcd.htm. Accessed August 7, 2016.

McCaig LF, Burt CW: Understanding and interpreting the National Hospital Ambulatory Medical Care Survey: Key questions and answers. Ann Emerg Med. 2012; 60(6): 716-721.