February 21, 2017

Your chances of long-term opioid use could hinge on who you see in the ED, study finds

Daily Briefing

    Individuals are more likely to use opioid drugs long-term if they are treated by ED physicians who prescribe opioids more frequently than their colleagues, according to a study published Wednesday in the New England Journal of Medicine, STAT News reports.

    Study details

    For the study, researchers looked at data on opioid prescribing to Medicare beneficiaries treated in hospital EDs between 2008 and 2011. The data included roughly 14,000 physicians who treated about 385,000 Medicare beneficiaries. The beneficiaries included in the data had not received opioids in the sixth months prior to their ED visit.

    The researchers did not investigate the possible link between ED opioid prescriptions and opioid-related substance use disorders. According to Reuters, opioid overdoses among elderly Medicare beneficiaries increased roughly fourfold between 1993 and 2012.

    Findings

    The researchers found that opioid prescribing frequency varies considerably among physicians working in the same ED. According to the researchers, some doctors were more than three times as likely as others to prescribe opioids to Medicare beneficiaries, with low-intensity prescribers giving opioids to 7.3 percent of their patients and high-intensity providers giving opioids to 24.1 percent of their patients.

    Further, the researchers found that patients treated by a high-intensity prescriber were about 30 percent more likely to use the drugs for six month or more within one year of their initial visit. According to the researchers, 1.51 percent of high-intensity prescribers' patients used opioids long-term, compared with 1.16 percent of low-intensity prescribers' patients.

    Based on their findings, the researchers estimated that roughly one in 48 Medicare beneficiaries who are prescribed a new opioid in the ED would use the drug long-term.

    Michael Barnett, an assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health, said the findings suggest high-intensity prescribers' patients "have worse outcomes that we weren't aware of before," not that those prescribers are "irresponsible in prescribing opioids to certain patients."

    For example, the researchers found that rates of hospital visits for complications that could be opioid related, such as falls and fractures, within one year of a patient's initial visit were "significantly higher" among those who saw a high-intensity prescriber.

    Discussion

    Barnett said variation in ED doctors' opioid prescribing patterns indicates that "there is no consensus among [ED] doctors who are treating similar patients about when to prescribe opioids and what dose to give." He added, "Doctors may have an intuitive sense, but when you rely on intuition, you get inconsistency."

    Barnett added that it is common for primary care physicians to refill opioid prescriptions that originated in the ED. He said, "In the clinical reality, it can be hard to say no to a patient who you think is really suffering."

    Michael Lyons, a researcher and emergency medicine doctor at the University of Cincinnati who was not involved in the study, said current efforts to reduce opioid prescribing take a "blunt instrument approach" aimed at reducing prescribing rates rather than investigating which patients should be treated and how. Lyons said, "What we really need is research to know whether this particular patient should get opioids. Then it would become possible to guide high- or low-prescribers to a common standard."

    (Armstrong, STAT News, 2/15; Barnett et al., New England Journal of Medicine, 2/16; Hoffman, New York Times, 2/15; Bernstein, "To Your Health," Washington Post, 2/15; Emery, Reuters, 2/15; Gold, Kaiser Health News, 2/15).

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