Willingness of Emergency MDs to Prescribe Painkillers Varies Widely

By Gene Emery

NEW YORK—A national comparison of emergency room physicians has uncovered a broad range of prescribing patterns for painkillers, and high-volume prescribers may be encouraging their long-term use among their elderly patients.

The analysis of the medical histories of more than 377,000 Medicare recipients found that frequent prescribers were 300% more likely to give out prescriptions for painkillers than low-volume physicians in the same hospital, and those heavy-prescribers were 30% more likely to give their patients prescriptions for longer periods.

Yet their patients were only 3% more likely to show up at the hospital to be treated for a long-term drug problem, compared with the patients of doctors who were more restrained in their prescribing habits.

"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," said the research team writing in the February 16 New England Journal of Medicine.

But it's not clear "whether this variation reflects overprescription by some prescribers and whether it is amenable to intervention," they concluded.

A 3% increase in hospitalization for opioid problems "isn't necessarily a large volume, but a little bit of a lot is still going to be a lot" which is why an increase risk for the elderly is a reason for concern, said Dr. Evan Schwarz of Washington University School of Medicine in St. Louis, who was not involved in the research.

He said he would have expected the 3% figure to be higher.

"To us, I think it's a bigger effect than it seems," chief author Dr. Michael Barnett of the Harvard T.H. Chan School of Public Health in Boston told Reuters Health by phone. "These are elderly folks who are coming to the emergency room who haven't been using opiates at all. This is not a high-risk population. We expect low rates."

And although the study relied on Medicare data, "we don't think this a phenomenon restricted to Medicare," he said. "It has the potential to be a larger issue than it seems on its face."

The observational study comes at a time when a 2010 estimate concluded that doctors prescribe enough opioid painkillers each year to give 5 milligrams of hydrocodone, also known as Vicodin, every four hours to every American adult for one month.

Among elderly Medicare patients, opioid overdoses quadrupled from 1993 to 2012. Not only does excessive opioid use spark addiction in this group, it increases their likelihood of deadly falls.

Whether the rates are increasing because doctors have become too quick to prescribe the drugs is a matter for debate, particularly when doctors often have little guidance for how to best use them.

"It's not like there's one approach that's going to magically not overtreat or not undertreat pain. It's hard," said Dr. Barnett. "But I think right now it's really a wild west of guesswork in terms of how we make decisions."

The study focused on emergency room physicians because patients coming into the emergency department usually don't know who will be treating them.

The researchers looked at Medicare records from 2008 to 2011. They did not study visits where the patients were admitted to the hospital and ultimately cared for by other doctors. People who had received an opioid prescription in the previous six months were also excluded.

Among the "high-intensity" prescribers (who gave out the drugs to 24.1% of their patients), the rate of long-term opioid use in their patients was 1.51%.

In comparison, among "low-intensity" prescribers (who were giving out opioid prescriptions to 7.3% of their patients), the rate was 1.16%.

Long-term use was defined as being given 6 months of narcotics.

The patients given more drugs were only 3% more likely to show up at a hospital within 12 months with an opioid-related drug problem, but the rates were high in both groups - 9.96% with high-prescribing doctors versus 9.73% with low-prescribing physicians (P=0.02).

The odds of a hospital visit for a fall or fracture were also significantly higher for the patients of high-prescribing doctors, but not spectacularly so. The rates were 4.56% over 12 months for those doctors versus 4.28% among doctors who were least-likely to prescribe painkillers, a 7% difference (P<0.001).

To see if the "low-intensity" prescribers might be giving an inadequate dose of painkillers, the researchers checked whether patients had returned to the hospital within 14 and 30 days with the same diagnosis. They found no indication that that inadequate pain treatment was a problem.

"The thing this study doesn't tell us is, was the prescription appropriate or why the high-volume providers are providing prescriptions," said Dr. Schwarz, who is chief of the medical toxicology section at Washington University. "We don't want to assume that all of this is inappropriate."

Both Drs. Schwarz and Barnett said the problem of overprescribing may be lessening.

"These data are coming from the peak of opioid prescribing because I think we've started to see a downturn, starting in 2015 or so," Dr. Schwarz said. "It may mean the pendulum is slowly starting to swing back in the other direction."

Contributing to the problem, he said, is the fact that "doctors frequently don't tell patients that opioids have a risk of developing some kind of dependence or chronic use. Many people might take a second look at whether they really want that prescription if the doctor actually told them about that risk."

SOURCE: https://bit.ly/2l1Vtzr

N Engl J Med 2017.

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