Special Topics in Pain: Opioids

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Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use.

Author(s): Barnett M L, et al.
Journal: N Engl J Med. 2017; 376:663-673. 29 references.
Reprint: Michael L. Barnett, MD, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Kresge Bldg., 4th Fl., 677 Huntington Ave., Boston, MA 02115. Email: mbarnett@hsph.harvard.edu
Faculty Disclosure: Abstracted by N Walea, who has nothing to disclose. Please see original article for disclosures.
Objective: Review and evaluate the latest advances and newest information in the area of Opioids

Editor’s Note: This study should be understood to be of Medicare recipients and may or may not be applicable to the general population. It found that ER physicians prescribing more opioids had more patients continuing to take them for 180 days after the index visit. Considering the REMS effort on opioids, 2013 and recently updated, this is disappointing and indicates a need for more physician and patient education.

Class: Pharmacology: Opioids in the ER

The extent to which individual physicians vary in opioid prescribing and the implications of that variation for long-term opioid use and adverse outcomes in patients are unknown. It is frequently argued that the prescribing behavior of physicians has been a driving factor in the opioid epidemic.

This was a retrospective analysis of Medicare beneficiaries who had an index emergency department visit between January 1, 2008 through December 31, 2011.

This was a 20% random sample of beneficiaries who had been continuously enrolled in Medicare Part D for 18 months or more, including at least the period from six months before the index visit to 12 months afterward. The study only included beneficiaries who had not had an opioid prescription filled in the six months before the index visit. Beneficiaries with hospice or cancer claims were excluded.

Physicians who treated the patients during the index visit were identified through the National Provider Identifier (NPI). Physicians with fewer than five emergency department visits were excluded and, if a physician practiced in more than one hospital, they were assigned to the hospital at which they had the most visits and other facilities were excluded. Physicians were grouped into quartiles of rates of opioid prescribing within each hospital and then classified as being in the top ("high-intensity opioid prescriber") or bottom ("low-intensity opioid prescriber") quartile of prescribing rates.

The primary outcome was long-term opioid use, defined as 180 days or more of opioid supplied in the 12 months after an index emergency department visit, excluding prescriptions within 30 days after the index visit. Secondary outcomes were rates of hospital encounters (emergency department visits, hospitalizations, or both), including those potentially related to adverse effects of opioids and those associated with a selection of medical conditions that were unlikely to be influenced by opioid use, in the 12 months after the index emergency department visit.

The sample consisted of 215,678 patients treated by a low-intensity opioid prescriber and 161,951 patients treated by a high-intensity opioid prescriber during an index emergency department visit. Characteristics and diagnoses of patients seen by high-intensity prescribers and those seen by low-intensity prescribers were similar.

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 (7.3% vs 24.1% of emergency department visits). Across all subgroups, prescribing rates among high-intensity prescribers were triple those among low -intensity prescribers. The highest average rate was seen among patients who visited the emergency department with an injury (23%). There was minimal correlation between physicians' prescribing rates and the median initial dose of an opioid prescription that was filled.

Overall, long-term opioid use at 12 months was significantly higher among patients treated by high-intensity prescribers than among patients treated by low-intensity prescribers (adjusted odds ratio 1.30; 95% CI, 1.23 to 1.37).

Rates of opioid-related hospital encounters and encounters for fall or fracture were significantly higher in the 12 months after the index visit among patients treated by high intensity opioid prescribers than among patients treated by low-intensity opioid prescribers (rates of any opioid-related encounter, 9.96 vs 9.73%; rates of encounter for fall or fracture, 4.56% vs 4.28%).

There was no significant difference in 12-month rates of overall hospital encounters or non-opioid-related encounters. Assessment of rates of short-term emergency department revisits for possible evidence of undertreated pain show that rates of 14-day and 30-day repeat emergency department visits with the same primary diagnosis as the index visit were similar in the two prescriber groups.

Important Points:
This study found variation by a factor of more than three in rates of opioid prescribing by emergency physicians within the same hospital and increased rates of long-term opioid use among patients treated by high-intensity opioid prescribers. These results suggest that an increased likelihood of receiving an opioid for even one encounter could drive clinically significant future long-term opioid use and potentially increased adverse outcomes among the elderly. Additional research is needed to explore whether this variation reflects overprescription by some prescribers and whether it is amenable to intervention.

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