A sprained ankle is a common, minor injury; yet a study shows that one quarter of adult patients who went to hospital emergency departments seeking treatment for it were prescribed opioids—and this was dramatically more likely in some states. In fact, patients in states that were "high prescribers" were about three times more likely to receive a prescription for the drugs than those in "low-prescribing" states, according to research led by M. Kit Delgado, MD, MS. And those who received prescriptions for long courses of the drugs (more than 30 tablets of oxycodone 5 mg) were five times more likely to fill additional opioid prescriptions over the next six months than those who were prescribed 10 tablets or fewer.
“Although opioids are not – and should not – be the first-line treatment for an ankle sprain, our study shows that opioid prescribing for these minor injuries is still common and far too variable,” said Dr. Delgado. “Given that we cannot explain this variation after adjusting for differences in patient characteristics, this study highlights opportunities to reduce the number of people exposed to prescription opioids for the first time—and also to reduce the exposure to riskier high-intensity prescriptions.”
The research team examined private insurance claims data from more than 30,800 patients who visited U.S. emergency departments for an ankle sprain from 2011 to 2015. None of the patients had filled an opioid prescription within the previous six months.
Some states contrasted more than tenfold: only three percent of patients received an opioid prescription in North Dakota, compared to 40 percent in Arkansas. The authors say the extreme variation between the two states could be explained by smaller sample sizes, despite the results being statistically significant. Nevertheless, the overall variation across states shows the need to reduce unnecessary prescribing for this condition.
“Although prescribing is decreasing overall, in 2015 nearly 20 percent of patients who presented with an ankle sprain were still given an opioid, a modest decrease from 28 percent in 2011,” Dr. Delgado said. “By drilling down on specific common indications as we did with ankle sprains, we can better develop indicators to monitor efforts to reduce excessive prescribing for acute pain.”
This study found high-intensity prescriptions were associated with prolonged use not related to the original injury; these findings support guidelines and policies that aim for smaller initial opioid prescriptions. However Delgado also has cautioned that while it is critical to minimize unnecessary opioid exposure, opioid prescribing for acute pain is not a one-size-fits-all situation. In an opinion piece published in the New England Journal of Medicine a few months following the study on sprains, Delgado and co-authors wrote, “Many patients require no opioids, whereas others may require more than three days of treatment, particularly if they have contraindications to non-opioid analgesics or lack access to timely follow-up care outside the emergency department. …. The overall goal is to curb unnecessary use and limit prescribing of medication for acute pain to patients who truly need it.”