After seeing dozens of patients in a hectic and long day in the clinic, when a doctor is faced with another patient in pain, it may be easiest to prescribe opioids and move on to the next one. New research suggests that doctors who practice with this habit could be contributing to the opioid epidemic.
A study published in JAMA Network Open on Friday reveals that physicians were more likely to prescribe opioids later in the day and when appointments were running behind schedule.
“Physicians play a crucial role in the opioid epidemic and it’s important to find the factors that drive decisions to prescribe opioids,” said Hannah Neprash, an assistant professor of health policy and management at the University of Minnesota and the study’s lead investigator. “Many studies have looked at looked at differences in prescribing patterns between physicians but few have looked at variation within physicians.”
The study utilized claims and electronic health data in 2017 for 678,319 patients with new pain who saw 5,603 physicians at health care clinics. The patients’ complaints ranged from back pain and headaches to muscle and joint aches. The researchers looked at the order of appointments and whether an appointment started at its scheduled time. Opioid prescriptions were compared to prescriptions of non-steroidal anti-inflammatory drugs and physical therapy.
Overall, physicians were 33% more likely to prescribe opioids later in the day and 17% more likely to do so if the appointment was running later than its scheduled time. NSAIDs and physical therapy prescribing did not change throughout the day.
When working with patients in pain who want opioids, offering them alternative therapies such as NSAIDs or physical therapy can require time-consuming discussions, Neprash said. “Prescribing opioids may be the quick fix when they do not have enough time to discuss non-opioid options.”
In 2017 there were six times the number of opioid related deaths compared to 1999. While much of the opioid epidemic is due to illicit drug use, prescription opioids still play a large role. The authors note that if prescribing practices remained constant throughout the day, 4,459 opioid prescriptions would not have been written in 2017.
The study draws attention to demands placed on doctors who are incentivized to see as many patients as possible. The authors recommend protocols to guard against physician fatigue, arguing that if time pressures are affecting opioid prescriptions, other major medical decisions could also be at risk.
Dr. Mark Linzer, director of the Office of Professional Worklife at Hennepin Healthcare in Minneapolis, said adding more clinical team members, such as physician assistants and nurse practitioners, could help diffuse the workload of the day and allow clinicians to spend more time with patients. He also proposed making individual visits longer for certain patients in order to provide the time needed to address pain and other sensitive medical problems.
“I suspect this is the tip of the iceberg: that time pressure has numerous adverse consequences, and that these poor outcomes could be attenuated by providing the time that complex patients (including those with acute and chronic pain) need with their clinicians,” said Linzer, who was not involved in the study.
“The conversation that avoids narcotics just takes time,” he said.
Adding more midlevels is a mixed bag.
Be careful what you wish for.
With this very valuable info: those needing opioids for serious pain should make late afterrnoon appointments. Those fumbling with lame excuses for a fix : the staff at MD offices (they too know the diference between patients) should book the abusers only morning appointments. And vote differently – get different / more caring and aware politicians at the helm in the US !!
The paranoidal USA health system needs a major overhaul, so that true pain patients are not left suffering due to Doctor’s and Pharmacist’s fear of the Big Hard Strong Threatening Fear-Mongering USA Super-Powers that have NO medical background. A pain patient is NOT an addict, and needs his/her meds. The stupidity of the USA government in not differentiating between (street) addicts and pain patients is an utterly cheap, stupid quick-fix attempt to solve a decades-old problem that will need much more depth to solve than simply cutting off access to opioids. All I can recommend is : move to Canada – the health system is much smarter there.
Reach out to Cindy Steinberg to become involved in pain advocacy at the Federal level. She also runs a pain support group in Arlington, near Boston. I am so sorry about your situation.
Making up an explanation to fit the data is not always the correct explanation. Mine is first the patient is in denial. The patient is aware of the potential danger of opioid use but it would never happen to him. Second the doctor feels he has adequately explained the dangers of opioid use and the patient says he understands and still wants treatment with opioids. The doctor is also in denial. Another problem is the opioid use not only eliminates the pain but causes a sense of euphoria. This pleasant feeling may even be better than pre-opioid use. If something makes you feel pleasant you may be inclined to use it more frequently and even in higher doses. No doubt biological and psychological tolerance also facilitate opioid abuse.
I am a 59 year old college graduate, mother and grandmother. I came here because I cannot sleep and suffer greatly. I will not do this much longer, go without. I’d rather go cold.
(The conversation that avoids narcotics takes time) That in my experience is not true. The people who have been destroyed and live in terrible pain from lupron do not get time. They just get no diagnosis live with all the bone pain, high blood pressure from pain , and doctors prescrible blood pressure medicine which is not correct. Also many other side effects that can not be denied. You want the whole true heartbreaking story contact me. And now they can not even get anything for pain.
How about using some common sense when prescribing? Instead, you are all using a one size fits all approach which is ignorant at best! How can you practice medicine when you KNOW you are harming people with painful conditions? This is going to cause even more problems than it has already! Think about how you will play a role in the inhumane actions that we are seeing. Will you go keep along with making people suffer needlessly? Will we see a shortage of doctors and nurses because they are too afraid the DEA will arrest them for doing their jobs? This is forced GENOCIDE at the hands of the medical professionals who could fight this for the patients they vowed to heal and ease the suffering of!