Patients Treated by Frequent Opioid Prescribers in ED Often Continue Use Long-Term

Medicare patients are more likely to continue using opioid painkillers a year after a visit to the emergency department (ED) if they had been treated there by a physician that frequently prescribes opioids, according to new research.

As part of efforts to identify drivers of the opioid abuse epidemic in America, prior research has demonstrated that rates of opioid prescriptions vary greatly by state. In 2012, for instance, the prescribing rate in Alabama, the highest-prescribing state, was 2.7 times higher than the rate in Hawaii, the lowest-prescribing state.

However, a recent study in the New England Journal of Medicine investigated whether physician-level prescribing patterns have an effect on long-term opioid abuse outcomes. Researchers collected claims data from Medicare beneficiaries who were prescribed an opioid during an ED visit and examined their likelihood of long-term opioid use 12 months after the visit.

The ED physicians who treated the sample patients were separated into quartiles based on the proportion of visits leading to an opioid prescription being filled, yielding groups of “high-intensity” prescribers in the top quartile and “low-intensity” prescribers in the bottom quartile. They were also classified by the median dose of opioids they prescribed during emergency visits.

Patient characteristics and diagnoses were similar whether treated by high-intensity and low-intensity prescribers; selection bias was not a concern as patients generally do not choose which physician will treat them in the ED. Within the same hospital, opioid prescribing rates varied significantly between the high-intensity prescribers, who prescribed opioids at 24.1% of visits, and the low-intensity prescribers, with a rate of just 7.3%.

The main outcome of the study was whether patients continued to use opioids long-term at 12 months after the initial emergency visit. As the study authors predicted, patients were more likely to experience long-term use if they had been treated by high-intensity prescribers. Those seen by the physicians in the highest quartile had an adjusted odds ratio for long-term use of 1.30 compared with the lowest-intensity quartile. These patients also had significantly higher rates of hospital encounters related to opioids and falls or fractures in the 12 months following their emergency visit. Furthermore, long-term opioid use was more common among patients treated by high dose-intensity prescribers.

The researchers acknowledged that their study could not assess whether the opioids were prescribed appropriately or were in fact unnecessary. However, their findings raised concerns about excessive prescribing in the ED, especially given the risks of long-term opioid use.

“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,” they concluded.