Health Policy Journal Club, Health Policy, Advocacy, Health Care Administration, Social EM, COVID-19

Health Policy Journal Club: Age Ain't Nothin' But a Number

Young Adults Prescribed More Opioids at Age 18 

Opioid use disorder (OUD) poses a great threat to public health. Since the late 1990s, opioid-related deaths have quadrupled and an estimated 130 people die per day from opioid-related drug overdoses. Opioid-related deaths reached their peak during the COVID-19 pandemic. This spike highlights the need for access to mental health and substance use disorder services, chronic pain treatment programs, and harm reduction strategies. Since many outpatient services were closed or restricted during much of COVID, emergency department (ED) providers likely played a larger role in opioid prescribing than in previous years. While OUD primarily affects adults ages 18-25, it also impacts adolescents. An estimated 66% of adults diagnosed with opioid use disorder used opioids for the first time before the age of 25. A recent article used insurance data to demonstrate the differences in adverse events, including rates of new-onset opioid use disorder (OUD), long-term opioid use and drug overdoses, between 17- and 18-year-old patients in the year after being prescribed an opioid in an emergency department. The authors hypothesized that those just below 18 are considered children and are often treated in pediatric settings and therefore have a decreased likelihood of being prescribed opioids compared to patients just over 18 years old who were treated like adults. To analyze this, the authors looked at insurance claims of patients who filled an opioid prescription within seven days of an ED visit and its association with an overdose or new diagnosis of OUD within one year. The results are staggering but expected. ED visits were followed by an insurance claim for an opioid prescription 14.4% of the time overall. More 18-year-old patients (15.3%) filled an opioid prescription than 17-year-olds (13.7%) and those who just turned 18 were more likely to receive a prescription than those who were just about to turn 18. Adverse events impacted 1.6% of the cohort overall, but predictably, numbers increased with age. While this article supports the authors’ hypothesis in terms of increased opioid prescriptions given to 18-year old’s vs 17-year old’s, it may actually underestimate the harms of opioid prescribing, as it only includes insured adolescents. The number of opioid-related adverse events is likely also underestimated in this study. Overall, this study reinforces the need for the maximization of non-opioid pain management among adolescents and young adults. The abrupt increase in prescribing at the age of 18 raises many questions regarding our prescribing practices and how we can best utilize education and initiatives to put an end to this trend. 


Article: Worsham CM, Woo J, Jena AB, Barnett ML. Adverse Events and Emergency Department Opioid Prescriptions in Adolescents. Health Aff (Millwood). 2021;40(6):970-978.

Understanding the risks associated with opioid prescription in adolescents is critical for informing opioid policy, but the risks are challenging to quantify given the lack of randomized trial data. Using a regression discontinuity design, we exploited a discontinuous increase in opioid prescribing in the emergency department (ED) when adolescents transition from "child" to "adult" at age 18 to estimate the effect of an ED opioid prescription on subsequent opioid-related adverse events. We found that adolescent patients just over age 18 were similar to those just under age 18, but they were 9.7% more likely to be prescribed an opioid and 12.6% more likely to have an adverse opioid-related event, defined as overdose, diagnosis of opioid use disorder, or long-term opioid use, within one year. We estimated a 14.1% increased risk for an adverse outcome when "adults" just over age 18 were prescribed opioids that would not have been prescribed if they were just under age 18 and considered "children."

Our results suggest that differences in care provided in pediatric versus adult care settings may be important to understanding prescribers' roles in the opioid epidemic. 

PMID: 34097510

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems. As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.