Opioid Prescription Patterns Among US Gastroenterologists From 2013 to 2017

Opioid and Nonopioid Analgesic Prescribing Patterns of Hepatologists for Medicare Beneficiaries

INTRODUCTION

Opioids are commonly prescribed to patients with chronic liver disease, but little is known regarding medication prescribing patterns of hepatologists. Opioid use increased until national guidelines limited opioid prescriptions in early 2016. We aimed to describe rates of opioid and nonopioid analgesics to Medicare beneficiaries by hepatologists from 2013 to 2017 and identify demographic characteristics associated with higher prescribing.

METHODS

Prescription data from 2013 to 2017 by 761 hepatologists identified in the Centers for Medicare and Medicaid Services Part D Public Use File were analyzed. Annual prescription volumes were compared for providers with >10 annual prescriptions of a given drug type. Provider characteristics associated with opioid prescriptions were identified through multivariate logistic regression analyses.

RESULTS

The proportion of hepatologists prescribing >10 annual opioid prescriptions decreased from 29% to 20.6%. Median annual opioid prescriptions per hepatologist significantly decreased from 24 to 20. Tramadol remained the most prescribed analgesic. Nonopioid analgesic prescription volume did not increase significantly. Provider characteristics associated with increased opioid prescriptions included male sex, practice location in the South and Midwest (vs West), more years in practice, and a greater proportion of beneficiaries who are white or with low-income subsidy claims. Characteristics associated with fewer prescriptions included non-university-based practice, having a greater proportion of female beneficiaries, and later prescription year.

DISCUSSION

Hepatologists are prescribing less opioids. However, the prevalence of tramadol use and the lack of increase in nonopioid analgesic use highlights the need for advancing the science and training of pain management in chronic liver disease and targeted implementation of nonopioid treatment programs.

High Opioid Prescribing Profiles Among Gastroenterologists: A Nationwide Analysis

Chronic opioid use is associated with adverse effects on the gastrointestinal (GI) tract and increased morbidity.^1-3 Despite efforts to de-escalate opioid use, 10% of outpatient GI visits are associated with an opioid prescription.⁴ Although we previously described declining opioid prescriptions to Medicare patients by most gastroenterologists,⁵ opioid prescriptions for GI conditions have increased.⁴ Considerable variation in opioid prescribing behavior exists in the general physician population, and a small percentage of high prescribers are responsible for driving opioid prescriptions.^6,7 The aims of this study are (1) to examine the impact of high opioid prescribers (HPs) on overall prescription volume in gastroenterology and (2) identify characteristics associated with HPs.

Gastroenterology Trainees' Attitudes and Knowledge towards Patients with Disorders of Gut-Brain Interaction

INTRODUCTION

Disorders of gut-brain interaction (DGBI) are highly prevalent, estimated to affect about 40% of the global population. Patients with DGBI are still inadequately treated and face stigma which adversely impacts their disease course.

METHODS

A 12-question multiple-choice anonymous survey was distributed electronically to all adult gastroenterology fellowship program directors across the United States. Data were collected on demographics, training, attitudes, and knowledge in managing patients with DGBI.

RESULTS

9.8% and 15.9% of all trainees reported that their attendings and peers often demonstrated a dismissive attitude towards patients with DGBI, respectively. 21.4% of all trainees often felt frustrated or burned out when seeing patients with DGBI with increasing odds of burnout by years of training (OR 4.4 for F3 trainees, trainees in their third year of training). Significantly, more female trainees reported frustration and burnout when seeing patients with DGBI (p = 0.005). 28.6% of all trainees report they often do not want to see patients with DGBI in their outpatient GI practice, including 39.6% of F3 trainees. 27.1% of F3 trainees reported that they were uncomfortable with titrating neuromodulators and only 31.6% of all trainees were comfortable knowing when to refer to a gastropsychologist.

DISCUSSION

Many trainees expressed some unwillingness and discomfort in managing patients with DGBI. Potential interventions will require a multi-pronged and longitudinal approach with education and training initiatives at the trainee level and beyond and exploring systemic healthcare delivery innovations to remove barriers.

A survey of gastroenterologists in the United States on the use of central neuromodulators for treating irritable bowel syndrome

BACKGROUND

Central neuromodulators are an effective treatment for irritable bowel syndrome (IBS) but may be used less frequently than other therapies.

AIMS

To survey gastroenterologists in the United States (US) about their use of neuromodulators in patients with IBS.

METHODS

A 23-question survey was distributed to gastroenterologists in the United States. Comparisons in prescribing practices were conducted between (a) gastroenterologists who were "high prescribers" versus "low prescribers" of neuromodulators in patients with IBS and (b) gastroenterologists and "gastroenterology experts" in the use of neuromodulators using descriptive statistics and multivariable logistic regression analyses.

RESULTS

The 525 gastroenterologists who were surveyed used neuromodulators for a median range of 21%-30% of their patients with IBS. Neuromodulators were described as extremely/very important in managing IBS by 55% of clinicians. Significant predictors of high-prescribing behaviour were academic versus clinical practice setting (odds ratio [OR] 2.60 [95% CI 1.61-4.20]), disorders of brain-gut interaction focused practice (OR 4.80 [2.60-8.84]), and greater perceived effectiveness of neuromodulators (OR 2.75 [1.30-5.84]). Compared to gastroenterologists, experts prescribed neuromodulators to a higher percentage of their patients with IBS (41%-50% vs 21%-30%; P = 0.019) and more frequently found neuromodulators effective (70% vs 27%; P = 0.003). However, concern about side effects was the most common barrier to neuromodulator use (59%).

CONCLUSIONS

The majority of US gastroenterologists believe central neuromodulators are important in treating IBS, and 27% believe they are effective in most patients. High prescribers are in academic practice, focus in IBS and perceive central neuromodulators as effective. Education is needed to improve gastroenterologists' prescribing behaviour.

Increasing Rates of Opioid Prescriptions for Gastrointestinal Diseases in the United States

INTRODUCTION

Pain control is an important management approach for many gastrointestinal conditions. Because of the ongoing opioid crisis, public health efforts have focused on limiting opioid prescriptions. This study examines national opioid prescribing patterns and factors associated with opioid prescriptions for gastrointestinal conditions.

METHODS

We conducted a repeated cross-sectional study using the National Ambulatory Medical Care Survey data from 2006 to 2016. The International Classification of Diseases codes were used to identify ambulatory visits with a primary gastrointestinal diagnosis. Data were weighted to calculate national estimates for opioid prescriptions for gastrointestinal disease. Joinpoint regression was used to analyze temporal trends. Multivariable logistic regression was used to examine factors associated with opioid prescriptions.

RESULTS

We analyzed 12,170 visits with a primary gastrointestinal diagnosis, representing 351 million visits. The opioid prescription rate for gastrointestinal visits was 10.1% (95% confidence interval [CI] 9.0%-11.2%). Opioid prescription rates for gastrointestinal disease increased by 0.5% per year from 2006 to 2016 (P = 0.04). Prescription rates were highest for chronic pancreatitis (25.1%) and chronic liver disease (13.9%) visits. Seventy-one percent of opioid prescriptions were continuations of an existing prescription. Patient characteristics associated with continued opioid prescriptions included rural location (adjusted odds ratio [aOR] 1.46; 95% CI 1.11-1.93), depression (aOR 1.83; 95% CI 1.33-2.53), and Medicaid insurance (aOR 1.57; 95% CI 1.15-2.13).

DISCUSSION

Opioid prescription rates for gastrointestinal disease visits increased from 2006 to 2016. Our findings suggest an inadequate response to the opioid epidemic by providers managing gastrointestinal conditions. Further clinical interventions are needed to limit opioid use for gastrointestinal disease.(Equation is included in full-text article.).

Impact of Opioid Consumption in Patients With Functional Gastrointestinal Disorders

Objective: We aimed to determine the burden of opioid consumption in a cohort of patients with functional gastrointestinal disorders.

Methods: All patients diagnosed with functional gastrointestinal disorders and referred to our university hospital were evaluated from 2013 to the beginning of 2019. Irritable bowel syndrome and functional dyspepsia diagnoses were determined according to Rome criteria and severity according to irritable bowel syndrome severity scoring system. Vomiting was quantified using a 5-point Likert scale, and constipation severity was measured using the Knowles-Eccersley-Scott-Symptom questionnaires. Quality of life was quantified by the GastroIntestinal Quality of Life Index. Patients were categorized as being treated on a chronic basis with either tramadol, step II opioids, step III opioids or as being opioid-free.

Results: 2933 consecutive patients were included. In our cohort, 12.5% had only irritable bowel syndrome, 39.3% had only functional dyspepsia, 24.9% had a combination of both, and 23.4% had other functional gastrointestinal disorders. Among them, the consumption of tramadol, step II (tramadol excluded) and step III opioids was 1.8, 1.3 and 0.3 % respectively in 2013 and 4.3, 3.4 and 1.9% in 2018 (p < 0.03). Opioid consumption was associated with increased vomiting (p = 0.0168), constipation (p < 0.0001), symptom severity (p < 0.001), more altered quality of life (p < 0.0001) and higher depression score (p = 0.0045).

Conclusion: In functional gastrointestinal disorders, opioid consumption has increased in the last years and is associated with more GI symptoms (vomiting, constipation and GI severity), higher depression and more altered quality of life.

Opioid Prescribing Patterns among Retina Specialists in the United States

PURPOSE

To determine the opioid prescribing patterns among retina specialists and to assess predictors for high-volume prescribing.

DESIGN

Retrospective cohort study.

PARTICIPANTS

American Society of Retina Specialists (ASRS) members in the 2013 through 2016 Medicare Part D Prescriber database.

METHODS

American Society of Retina Specialists members within the United States were profiled from the ASRS member directory as of April 2019. The Centers for Medicare and Medicaid Services Medicare Part D Prescriber Public Use Files for 2013, 2014, 2015, and 2016 were accessed. Data were collected and analyzed regarding the prescribing patterns for opioid drugs for all participating ASRS members.

MAIN OUTCOME MEASURES

Mean number of opioid prescriptions written annually by retina specialists, prescriber rates compared with all prescriptions written, and geographic distribution of opioid prescriptions written by retina specialists.

RESULTS

The authors identified 1518 ASRS members in the Medicare database in 2016. Members had written a total of 14 127 prescriptions in 2016, with 66% of members writing at least 1 opioid prescription. On average, members wrote 11 opioid prescriptions per year. Almost one fifth (21%) wrote more than 10 prescriptions annually. A minority (6%) wrote more than 50 prescriptions. Among those writing more than 10 prescriptions annually, approximately 35 opioid prescriptions were written annually with a mean supply of 4 days. Using multivariate analysis, the factors associated with increased number of opioid prescriptions were male gender (β = 2.80; P < 0.001), a practice location in the South (β = 5.61; P < 0.001), and larger patient panel size (β = 0.029; P < 0.001). The total number of opioid prescriptions, including refills, written by members also decreased by 18% from 2013 to 2016 (P < 0.001).

CONCLUSIONS

American Society of Retina Specialists members prescribed opioids at a rate (1.5%) lower than the national mean of all prescribers across all medical specialties (6.8%). Male gender and a practice location in the South were correlated to number of prescriptions. Further research is needed to elucidate the appropriate indications for the prescription of opioids among retina specialists.