Medications Used in U.S. Emergency Departments for an Ankle Sprain: An Analysis of the National Hospital Ambulatory Medical Care Survey.
Kosik KB, Hoch MC, Humphries RL, Villasante Tezanos AG, Gribble PA. J Emerg Med. 2019 Oct 9. pii: S0736-4679(19)30677-8
More than half of patients seen at an emergency department for an ankle sprain receive NSAIDS, and almost 3 out of 10 patients receive an opioid.
Practice guidelines for acute ankle sprains recommend rest, ice, compression, elevation, exercises (supervised or at home), and nonsteroidal anti-inflammatory drugs (NSAIDs). However, we know little about how often and what type of medication is prescribed after an ankle sprain. This information is important since there is a risk of misuse of prescription drugs. Therefore, the authors used the National Hospital Ambulatory Medical Care Survey to describe how often a patient received a prescription for medicine during an emergency department visit for an ankle sprain between 2006 to 2015. The authors excluded any patient with multiple diagnoses at discharge. The authors adjusted all of the findings to reflect what we could expect throughout the United States. Between 2006 to 2015, the authors found emergency departments treated more than 9 million isolated ankle sprains. Medication was given or prescribed at ~76% of the ankle sprain visits. A patient typically received a single medication (~49%). Furthermore, a patient often received an NSAID (~54%) or opioid analgesic combination (28%, e.g., acetaminophen-oxycodone). From 2009-2010 the percentage of NSAIDs being prescribed increased by ~13%, while opioid analgesic combination decreased by ~12%.
Overall, the authors found that 3 out of 4 patients with an isolated ankle sprain received a prescription from the emergency department, typically at discharge. It is not surprising that the most commonly prescribed drug was an NSAID, as this is consistent with current practice guidelines for the conservative management of an ankle sprain. However, clinicians should follow-up with these patients to monitor the onset of side effects (e.g., gastrointestinal bleeding). Furthermore, we should be cautious until more prospective studies can help us understand their effect on long-term recovery. Another alarming fact was that almost 3 out of 10 patients received an opioid analgesic combination. Due to the potential consequences associated with their use patients and health care professions should consider alternative conservative methods (RICE or physical rehabilitation) with NSAIDS instead of opioid analgesics as the first line of defense when managing isolated ankle sprain symptoms. It would be interesting to know how many patients received advice or referral to see an athletic trainer or physical therapist. This referral may be a key step to preventing long-term complications (e.g., chronic ankle instability, medication misuse). Lastly, sports medicine clinicians should follow-up with a patient after an emergency department visit for an ankle sprain to ask what was prescribed, educate the patient about the medication (e.g., proper use, side effects), and initiate other conservative treatment strategies.
Questions for Discussion
Do you see your athletes being prescribed opioids? Do you talk to your athletes about opioid prescription drug use?
Written by: Jane McDevitt
Reviewed by: Jeffrey Driban
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I find it interesting that the emergency room is prescribing opioids for ankle sprains. As a student-athlete and an athletic training students I have witness athletic trainers give athletes over the counter NSAIDS to athletes at the beginning stages of an ankle sprain to help with pain and swelling. However, I haven’t seen a ton of athletes being prescribed opioids. The athletes that I have seen prescribed opioids are those that had surgery. From the student-athlete side I have never talked to an athletic trainer about opioid prescription use. Also from the athletic training side I haven’t talked to athletes about prescription opioid use. I think that prescribing strong NSAIDS and/or opioids for an ankle sprain is a little excessive and unnecessary.
Throughout the course of the semester and the duration of the athletic training program, we have been taught to implement the use of over the counter NSAIDs for the treatment of acute pain and inflammation. However, we have never touched on the topic of prescription medications for our athletes for chronic pain or those who have been given prescriptions from their or the team physician. During my clinical career as a student, I have only seen one ankle sprain, that later turned out to be a distal fibular fracture. Even in this case, the person was only prescribed Indocin for the first few weeks and then turned to over the counter NSAIDs.
In my opinion, opioid pain medications should only be prescribed for fractures fo and surgery. However, I am not an MD or surgeon and this would be out of my scope of practice as a future ATC.
Tallie, your bring up a great point. I do not think we ATs often consider the fact that our athletes could be prescribed opioids for their pain following an ankle injury. I think during a follow up evaluation noting if they went to the doctors or ER asking documenting what kind of medication would be appropriate so we can follow through with other pain management strategies and keep an eye for any signs of misuse.
Sebastian, I agree that I feel it is the doctors job to provide NSAIDS especially if there is a lot of swelling; however there are definitely other pain management strategies. I was recently talking to one of the Co-Authors of this paper and he found that while studying this topic only 7% receive prescription to even go for therapy. We really need to advocate that we can help lateral ankle sprain patients that we have strategies and techniques to decrease pain and swelling. Also, one thing I have been thinking about is if they are prescribing opioids for lateral ankle sprains what other injuries are they prescribing medications for. Again, any time an athlete sees a doctor or ER I think we need to continue to follow up on if they were prescribed medication and ensure they are taking it correctly and not abusing it.
I’m surprised that an ER doctor would prescribe an opioid for an ankle sprain. I haven’t seen any prescribed medications for such a common musculoskeletal injury. As an ATS we do let athletes know they can take over the counter NSAIDs to help with their pain and swelling, I feel it would be more appropriate for an ER doctor to do the same instead of prescribing. Especially because of the opioid crisis in the US. I’ve only seen athletes who have fractures, surgeries, or other major injuries be prescribed opioids. I liked that they mention the advice or referral to see an AT for an ankle sprain. It could be beneficial for ER doctors/nurses to ask if the patient has access to an AT and then suggest the individual sees them. If they do, an AT can do more for them than an ER doctor can for the sake of treatment, rehabilitation, and preventative actions.
I believe most talk about opioid use would be at the collegiate settings because of drug testing and the more strict rules about what athletes can take. Although, it should be incorporated in any setting including high schools or younger.
I’m surprised that an ER doctor would prescribe an opioid for an ankle sprain. I haven’t seen any prescribed medications for such a common musculoskeletal injury.
Briana and w88top,
I agree this was alarming. That is why research like this is so important to draw awareness. Briana, I think that is a great idea; however, there are so many schools that do not have ATs. We need to push to advocate that schools that have sports need an AT. Then, we as ATs need to follow up with patients and ask about what kind of care they were provided and what medications were prescribed.
I also think we need to educate our athletes that we can help with pain during the rehab process and ensure they are not turning to opioids.
I find it interesting that an ER would prescribe an athlete NSAIDs at discharge for just a basic ankle sprain. As an athletic training student, we rarely bring an athlete to the hospital if we think it is just an ankle sprain. We only transport an athlete if we think there may be a fracture, dislocation, or anything more serious. My preceptor has had discussions with athletes about the proper use of NSAIDs for pain management in the acute phase of an ankle sprain but has never had to deal with a hospital prescribing unnecessary medication for an ankle sprain. I personally think that if the pain is tolerable then there is no need to mask the pain with medication because there are so many other ways to deal with pain from a clinician’s standpoint. I have also never seen an athlete be prescribed an opioid at discharge for a basic ankle sprain and i think that is quite excessive to be used pain management of one.
I am only an AT student, but I have not seen any Athletes being prescribed opioids for isolated ankle sprains. What I do typically see is an athlete receiving over the counter NSAIDS from the ATC, which as stated is consistent with the current practice guidelines. The opioid analgesic prescription appears to be excessive for any ankle sprain that is grade II or below. It would be interesting to see what grade ankle sprain the opioid-analgesic were being prescribed for. I have never seen my preceptors discuss the use of opioids with their patients, however, I know that the departments have pamphlets readily accessible. I personally have never spoken with any athletes about the use of opioids. With the above stated, it would be beneficial to have the student athlete population educated about the opioid epidemic, whether that was led by student health services or the sports medicine department should be a decision made by each entity.
After reading this review, it’s very interesting how a hospital will give out opioids for an ankle sprain. In my opinion, opioids are very unnecessary for an athlete and/or student athlete. As an athletic training student, I have not seen any of my athletes or patients being prescribed opioids. Doing clinical rotations at a high school, as an AT, we weren’t allowed to administer any medications. That’s what the school nurse was for. Also, doing rotations at a PT clinic, medications were not prescribed or administered. All I’ve ever seen was over the counter NSAIDS given out. Its only but so much an AT is allowed to give you in one day. Therefore, especially being an athlete, they are built to push through pain and when it gets to that point, some will endure the pain and others will just receive NSAIDS, but never opioids. Like Erika said, its other ways to deal with pain. But being prescribed opioids is excessive. As of talking to athletes about the use of opioid prescription drug use, I’ve never done. If something were to be discussed about that particular drug use, it would be with my preceptor and asking her opinion about it being prescribed. And even for the ankle sprain, sometimes NSAIDS aren’t needed after the first day. That’s when the athlete will begin modality work or rehab depending on what grade it is.
After reading this article, I am pretty shocked that emergency rooms and hospitals are prescribing opioids for acute ankle sprains. As an athletic training student, my preceptors and myself have seen/experienced a multitude of ankle sprains, majority of which my athletes can shake off and persevere through. In my experience I have not seen or heard of any athletes taking opioids for ankle sprains, and honestly I think its a bit unnecessary. I believe NSAIDs would be just as beneficial and would decrease the risk of medication misuse. I do agree with others on following up with athletes if the ankle sprains were bad enough or happened outside of school/ATC awareness and were sent to the ER, if opioids/medications were prescribed is a great idea. Another factor I found shocking from this article was the amount of isolated ankle sprains that were encountered over the course of 9 years… 9 million, is crazy to me. I understand this is not limited to the sports/athletics population, however that number is still pretty high, and I would have never guessed that amount. So far in my experience I have not had to talk to my athletes about opioid prescription drug use, nor have I had the chance to witness it. I have seen ankle sprains evaluated, diagnosed, and treated with basic NSAIDs and rehabilitation protocols. Overall I found this article interesting and full of information I was not aware of, and being an athlete as well as an Athletic Training student, I believe there are other and better ways to cope with pain rather than opioid use.
Overall this was a very interesting article. I am surprised with the numbers and I did not expect them to be so high. Being that my clinical site is a high school setting, I certainly have not seen opioids been considered or prescribed, let alone given to any of the athletes. Even all of my two years of being an AT student, i’ve only seen over the counter drugs used. Being that I am currently in a high school setting, a parental consent has to be signed in order for an athlete to receive any type of drugs. 76% is a huge percentage. Opioids is a bit excess and I do not see the necessity of it. I do agree that NSAIDS should be used instead of opioid analgesics as the first line of defense when managing isolated ankle sprain. I personally have seen that and been a process of suggesting that almost every athlete I’ve treated. Also, every athletic trainer I’ve shadowed uses NSAIDs with exercises and that is only the first few days post injury. I can see and understand why opioids would be used after a surgery, fracture etc.. but not for an acute ankle sprain. Overall, this article was very informative.