February 16, 2017
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Physician prescribing patterns may help determine risk for long-term opioid use

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Patients treated in the ED by physicians who prescribe opioids at a higher intensity are at greater risk for long-term opioid use than those who see low-intensity prescribers, according to a study that recently appeared in the New England Journal of Medicine.

In light of the ongoing opioid epidemic, the authors sought to better quantify the role of the clinician in long-term opioid use.

“It is commonly thought that opioid dependence often begins through an initial, possibly chance, exposure to a physician-prescribed opioid, although data from studies to empirically evaluate this claim are lacking,” Michael L. Barnett, MD, assistant professor of health policy and management at the Harvard Chan School, and colleagues wrote. “Our results provide evidence that this mechanism could drive initiation of long-term opioid use through either increased rates of opioid prescription or prescription of a high, versus a low, dose of opioid.”

Barnett further elaborated on the results in a press release.

"These are sobering results," he said.  "Our analysis suggests that one out of every 49 people newly prescribed an opioid will become a long-term user. That's a big risk for such a common therapy."

Researchers categorized the emergency physicians as high-intensity or low-intensity opioid prescribers based on their opioid prescribing rates.

Barnett and colleagues retrospectively analyzed 215,678 patients treated by low-intensity opioid prescribers and 161,951 patients treated by high-intensity opioid prescribers. All patients had similar characteristics and were Medicare beneficiaries who had an index ED visit from 2008 through 2011 and had not received an opioid prescription within 6 months prior to that visit. The researchers also compared rates of long-term opioid use (categorized as 6 months of days supplied) in the 12 months after a visit to the ED among patients treated by high-intensity or low-intensity prescribers.

They reported that within individual hospitals, rates of opioid prescribing in ED visits were 7.3% among low-intensity prescribers and 24.1% among those at the high-intensity prescribers. The average rate, of the initial rate of opioid prescription in ED was 14.7% Researchers also reported high-intensity prescribers were three times more likely to prescribe opioids across all subgroups. In addition, 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 (aOR = 1.3; 95% CI, 1.23-1.37, P < .0001).

Researchers stated their study had limitations, such as that the study was observational, the limited ability to quantify the extent of opioid overuse and only looking at patients enrolled in Medicare Part D and visiting an ED during a certain time frame.

“In conclusion …. 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. Future research may explore whether this variation reflects overprescription by some prescribers and whether it is amenable to intervention,” researchers wrote.

"Who treats you matters. Our findings lend support to the narrative that we often hear — a patient happened to be prescribed an opioid by a dentist or in the emergency room and unwittingly became a long-term user," Anupam Jena, MD, PhD, associate professor of Health Care Policy at Harvard Medical School, said in the release. "A physician who prescribes an opioid needs to be conscious that there is a significant risk that the patient could continue to be on an opioid for the long term, even from a single, short, initial prescription."

Citing the “epidemic of overdose deaths,” the CDC issued guidelines for primary care physicians and other medical professionals for opioid prescriptions last year. Over the past several months, the FDA has approved several pain relief agents that are specifically manufactured to make them more difficult to abuse. – by Janel Miller

Disclosure: Barnett reports being a medical advisor to and holding stock in Ginger.io; Jena reports receiving consulting fees from Pfizer, Hill-Rom Services, Bristol-Myers Squibb, Novartis Pharmaceuticals, Vertex Pharmaceuticals, and Precision Health Economics. Please see the study for a list of all other relevant financial disclosures.