Whether patients leave a hospital emergency room with a prescription for opioid painkillers may well depend on one, often random factor: which doctor treats them. And a new study suggests that chance encounter can have far-reaching impact, possibly setting up some patients to become long-term users of the drugs.
The study in this week’s New England Journal of Medicine found wide variation in the prescribing habits of doctors working in in the same emergency departments. Some doctors were three times as likely to prescribe painkillers for patients with similar ailments as their colleagues.
The patients treated by the frequent prescribers were 30 percent more likely to have become long-term opioid users within a year of their visit, the researchers found. The study examined the prescribing of 14,000 doctors, and then compared the practices of doctors within the same emergency department. The nearly 400,000 Medicare patients studied had not received an opioid prescription in the prior six months.
“Who treats you matters,” said Dr. Anupam Jena, a study author and physician at Massachusetts General Hospital. “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.”
While the study focused on emergency room doctors, the authors said there’s no reason to believe the same phenomenon wouldn’t be seen in other health care settings.
The study suggests that about 1 of every 48 people newly prescribed an opioid will become a long-term user – a number that constitutes a significant potential risk given nearly 300 million opioid prescriptions are written each year in the United States.
The huge disparity in prescribing points to another problem. Despite intense scrutiny in recent years of physician prescribing of opioids, detailed clinical guidance on when to prescribe opioids, for what conditions, and in what amounts are lacking in many areas of health care.
“With opioids, there is a lot of guesswork,” said another study author, Dr. Michael Barnett of the Harvard T.H. Chan School of Public Health. “The current state of affairs at the extreme is that doctors are improvising as they go along. We need more scrutiny of how we do things.”
The researchers found that rates of hospital visits for complications such as falls or fractures that could be opioid-related were “significantly higher” among the patients who saw a physician in the high opioid-prescribing group in the year after their initial visit.
There is also concern that long-term opioid use sparked by a legitimate hospital or doctor visit could lead to opioid addiction. A study in The Practice of Emergency Medicine last year found that emergency room opioid prescriptions may contribute to the development of addiction in some patients. The study, however, involved a small number of patients and was based on the self-reported drug history of those patients.
The NEJM study did not make any findings about the possibility of emergency room prescriptions leading to opioid drug dependence, and noted there is a paucity of studies examining the link.
Michael Lyons, a researcher and emergency medicine doctor at the University of Cincinnati, said the potential link between legitimate physician prescriptions for opioids and addiction is an area that “needs research badly and quickly.”
“A single, brief exposure to opioids won’t cause addiction, but you have to wonder if that initial exposure is part of the story,” he said. “I think it is a real question. We don’t know how often under what circumstances the first exposure is either avoidable or launches a spiral towards addiction.”
At the same time, he said current efforts aimed at reducing opioid prescribing are taking a “blunt instrument approach” focused on physician prescription rates rather than which patients should be treated with opioids, for how long, and at what dose.
“What we really need is research to know whether this particular patient should get opioids,” he said. “Then it would become possible to guide high- or low-prescribers to a common standard.”
The researchers looked only at patients in Medicare, the government insurer for the elderly. Barnett said he would expect to see disparities in prescribing among other patient groups and in other medical specialties.
He also said the NEJM study is not meant as a critique of emergency room prescribing. The emergency room setting was selected because the patient population seen by doctors at the same hospital is similar and patients usually are randomly assigned a doctor to treat them.
In fact, a 2015 study found that the biggest decline in opioid prescribing among specialists from 2007 to 2012 occurred among emergency medicine doctors. The same study estimated emergency room doctors wrote 12.5 million opioid prescriptions in 2012, which is a little less than 5 percent of the national total.