By Ajay K. Singh, MBBS, FRCP, MBA
February 22, 2017
What type of doctor holds the moral high ground on opioid prescribing? Some claim it is held by doctors who believe that pain is the “fifth vital sign.” They prescribe opioids for both acute and chronic pain. They point out that withholding effective pain relief is unconscionable. Others believe that the moral high ground is held by those who rarely prescribe opiate analgesics: yes, for acute pain and, worried about the possibility of abuse, rarely for chronic use, and then only in limited quantities.
Still, at its heart, the debate centers on the importance of a doctor’s prescribing practice in driving opioid addiction.
A paper this past week from the Harvard School of Public Health and Harvard Medical School published in the New England Journal of Medicine by Barnett and colleagues raises substantial concerns about emergency room opiate prescribing habits. It represents a wake-up call to all doctors, but especially ER docs who are frequently at the frontline of treating pain.
Barnett and colleagues retrospectively studied Medicare Part D beneficiaries who had an index emergency department visit in the period from 2008 through 2011, but had not received prescriptions for opioids within six months before that visit. They identified the ER doctors who cared for the patients and categorized them into either high-intensity or low-intensity opioid prescribers. They then compared rates of long-term opioid use among patients treated by high-intensity or low-intensity prescribers, adjusted for patient characteristics.
In their study, 215,678 patients received treatment from low-intensity prescribers and 161,951 patients from high-intensity prescribers. Within individual hospitals, they observed that opioid prescribing rates were very different between low-intensity and high-intensity prescribers (7.3% vs. 24.1%). As well, long-term opioid use was 30% higher over the subsequent 12 months among patients treated by high-intensity prescribers than among patients treated by low-intensity prescribers (adjusted odds ratio, 1.30; 95% confidence interval, 1.23 to 1.37; P<0.001).
Because it is a retrospective study, it is open to lots of different types of bias. They address these, at least in part, by comparing ER doctors within the same hospitals. They also adjust for a variety of patient factors. Another major limitation is that Medicare Part D patients are elderly and so the results may not be generalizable to all long-term opioid users.
However, the study does highlight the substantial variability of prescribing opiate analgesic agents within the same emergency department, raising questions about education of physicians and monitoring of prescribing habits.
The study also points to the longer-term impact of zealous prescribing of opiate analgesics on the likelihood of addiction among elderly patients.
As the authors state: “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.”
Opioid Use Disorder Education Program
Learn more about the latest medical and psychosocial treatment options, best practices, and legal guidelines for treating and managing OUD patients in a free online program produced by Harvard Medical School with scientific contributions from the National Institute on Drug Abuse (NIDA). The following three accredited courses are open for enrollment and intended for physicians, nurses, nurse practitioners, physician assistants, social workers, and other health care providers collaborating to treat patients with substance use disorders:
Identification, Counseling, and Treatment of Opioid Use Disorder
Collaborative Care Approaches for the Management of OUD
Dr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.