In the ED, Patient Opioid Abuse May Come Down to the Doctor

Nicola M. Parry, DVM

February 16, 2017

Opioid prescribing patterns vary widely among physicians in the same emergency department, and the difference appears to affect patients' long-term outcomes, a study published online February 15 in the New England Journal of Medicine shows.

"On average, rates of opioid prescribing between low-intensity prescribers and high-intensity prescribers varied by a factor of 3.3 within the same hospital," write Michael L. Barnett, MD, from the Harvard T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts, and colleagues.

"The intensity of a physician's opioid prescribing was positively associated with the probability that a patient would become a long-term opioid user over the subsequent 12 months," they add.

The number of opioid prescriptions has risen dramatically in the United States in recent decades, as have the number of deaths from opioid overdose. This epidemic has increasingly included seniors, who are particularly vulnerable to the sedating side effects of opioids, even at therapeutic doses.

Although the opioid epidemic may be partly driven by physicians' variable prescribing, including overprescribing, of opioids, few studies have investigated these factors and how they affect patient outcomes, according to the authors.

Dr Barnett and colleagues conducted a retrospective study of Medicare beneficiaries who had a first emergency department visit between 2008 and 2011 and who had not used prescription opioids in the 6 months before the visit.

To examine variability in rates of opioid prescribing among emergency physicians within the same hospital, the researchers divided the physicians into quartiles according to prescribing intensity. They found that opioid prescribing rates among frequent prescribers, defined as those in the top quartile, were more than triple the rates among infrequent prescribers, defined as those in the lowest quartile, within the same hospital (24.1 vs 7.3%; P < .001).

To examine how prescribing patterns might affect patients' long-term opioid use, the researchers analyzed data from 215,678 patients who received treatment from infrequent prescribers, and 161,951 who received treatment from frequent prescribers. They defined long-term opioid use as 180 days or more in which opioids were given within 12 months after a first emergency department visit, excluding those prescribed within the first 30 days.

Patients treated by frequent prescribers were significantly more likely than those treated by infrequent prescribers to become long-term opioid users (1.51% vs 1.16%; adjusted odds ratio, 1.30; 95% confidence interval [CI], 1.23 - 1.37; P < .001) and were more likely to experience an adverse outcome related to the drugs, such as a fall or a fracture (4.56% vs 4.28%; adjusted odds ratio, 1.07; 95% CI, 1.03 - 1.11; P < .001).

"This finding corresponds to a number needed to harm of 49 patients receiving an opioid prescription to theoretically lead to 1 excess long-term opioid user," they explain.

"[T]his is a low number needed to harm for such a common therapy," they write.

However, they also point out that patients would need to receive opioid prescriptions from other physicians after an emergency department visit for long-term opioid use to develop. Clinical inertia, whereby outpatient clinicians continue to provide prescriptions that had been written previously, could help explain this, they add.

The authors acknowledge the limitations of their study, including its observational nature, which precludes interpreting the findings as causal. Because they were also unable to determine whether an opioid prescription was appropriate, they could not quantify the extent of opioid overuse. The researchers also stress that the results cannot be generalized to other patient populations, because they focused on Medicare patients with Part D enrollment who visited emergency departments.

This study received funding from the National Institutes of Health. Dr Barnett is a medical advisor to and holds stock in; he also has a pending patent related to a method for using physician social networks to predict cost and intensity of care in hospitals. One coauthor has received personal fees from Pfizer, Hill-Rom Services, Inc, Bristol-Myers Squibb, Novartis Pharmaceuticals, Vertex Pharmaceuticals, and Precision Health.

N Engl J Med. Published online February 15, 2017. Full text

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