Variations in Opioid Prescribing Behavior by Physician Training

The association between primary care appointment lengths and opioid prescribing for common pain conditions

BACKGROUND

While brief duration primary care appointments may improve access, they also limit the time clinicians spend evaluating painful conditions. This study aimed to evaluate whether 15-minute primary care appointments resulted in higher rates of opioid prescribing when compared to ≥ 30-minute appointments.

METHODS

We performed a retrospective cohort study using electronic health record (EHR), pharmacy, and administrative scheduling data from five primary care practices in Minnesota. Adult patients seen for acute Evaluation & Management visits between 10/1/2015 and 9/30/2017 scheduled for 15-minute appointments were propensity score matched to those scheduled for ≥ 30-minutes. Sub-groups were analyzed to include patients with acute and chronic pain conditions and prior opioid exposure. Multivariate logistic regression was performed to examine the effects of appointment length on the likelihood of an opioid being prescribed, adjusting for covariates including ethnicity, race, sex, marital status, and prior ED visits and hospitalizations for all conditions.

RESULTS

We identified 45,471 eligible acute primary care visits during the study period with 2.7% (N = 1233) of the visits scheduled for 15 min and 98.2% (N = 44,238) scheduled for 30 min or longer. Rates of opioid prescribing were significantly lower for opioid naive patients with acute pain scheduled in 15-minute appointments when compared to appointments of 30 min of longer (OR 0.55, 95% CI 0.35-0.84). There were no significant differences in opioid prescribing among other sub-groups.

CONCLUSIONS

For selected indications and for selected patients, shorter duration appointments may not result in greater rates of opioid prescribing for common painful conditions.

Influences of Software Changes on Oxycodone Prescribing at an Australian Tertiary Emergency Department: A Retrospective Review

Opioid prescribing and dispensing from emergency departments is a noteworthy issue given widespread opioid misuse and diversion in many countries, contributing both physical and economic harm to the population. High patient numbers and the stochastic nature of acute emergency presentations to emergency departments (EDs) introduce challenges for prescribers who are considering opioid stewardship principles. This study investigated the effect of changes to electronic prescribing software on prescriptions with an auto-populated quantity of oxycodone immediate release (IR) from an Australian tertiary emergency department following the implementation of national recommendations for reduced pack sizes. A retrospective review of oxycodone IR prescriptions over two six-month periods between 2019 and 2021 was undertaken, either side of a software adjustment to reduce the default quantities of tablets prescribed from 20 to 10. Patient demographic details were collected, and prescriber years of practice calculated for inclusion in linear mixed effects regression modelling. A reduction in the median number of tablets prescribed per prescription following the software changes (13.5 to 10.0, p < 0.001) with little change in the underlying characteristics of the patient or prescriber populations was observed, as well as an 11.65% reduction in the total number of tablets prescribed. The prescriber's years of practice, patient age and patient sex were found to influence increased prescription sizes. Reduced quantity of oxycodone tablets prescribed was achieved by alteration of prescribing software prefill parameters, providing further evidence to support systems-based policy interventions to influence health care providers behaviour and to act as a forcing function for prescribers to consider opioid stewardship principles.

Effect of Didactic Training on Barriers and Biases to Treatment of Opioid Use Disorder: Meeting the Ongoing Needs of Patients with Opioid Use Disorder in the Emergency Department during the COVID-19 Pandemic

In the wake of COVID-19, morbidity and mortality due to Opioid Use Disorder (OUD) is beginning to emerge as a second wave of deaths of despair. Medication assisted treatment (MAT) for opioid use disorder MAT delivered by Emergency Medicine (EM) providers can decrease mortality due to OUD; however, there are numerous cited barriers to MAT delivery. We examined the impact of MAT training on these barriers among EM residents in an urban, tertiary care facility with a large EM residency. Training included the scripted and standardized content from the Provider Clinical Support System curriculum. Residents completed pre- and post-training surveys on knowledge, barriers, and biases surrounding OUD. We performed Wilcoxon matched-pairs signed-ranks test to detect statistical differences. Of 74 residents, 49 (66%) completed the pre-training survey, and 34 (69%) of these completed the follow-up survey. Residents reported improved preparedness to treat aspects of OUD across all areas queried, reported decreased perception of barriers to providing MAT, and increased comfort prescribing naloxone, counseling patients, prescribing buprenorphine, and treating opioid withdrawal. A didactic training on MAT was associated with residents reporting improved comfort providing buprenorphine and naloxone. As the wake of morbidity and mortality from both COVID and OUD continue to increase, programs should offer dedicated training on MAT.

Opioid Prescription Following Wrist and Ankle Fracture Fixation in Scotland—Tradition Prevails

The American ‘opioid crisis’ is rapidly spreading internationally. Perioperative opioid use increases the risk of long-term opioid use. We review opioid use following wrist and ankle fracture fixation across Scotland, establishing prescribing patterns and associations with patient, injury, or perioperative factors. Six Scottish orthopedic units contributed. A total of 598 patients were included. Patient demographics were similar across all sites. There was variation in anesthetic practice, length of stay, and AO fracture type (p < 0.01). For wrist fractures, 85.6% of patients received a discharge opioid prescription; 5.0% contained a strong opioid. There was no significant variation across the six units in prescribing practice. For ankle fractures, 82.7% of patients received a discharge opioid prescription; 17% contained a strong opioid. Dundee and Edinburgh used more strong opioids; Inverness and Paisley gave the least opioids overall (p < 0.01). Younger patient age, location, and length of stay were independent predictors of increased prescription on binary regression. Despite variability in perioperative practices, discharge opioid analgesic prescription remains overwhelmingly consistent. We believe that the biggest influence lies with the prescriber-institutional ‘standard practice’. Education of these prescribing clinicians regarding the risk profile of opioids is key to reducing their use following surgery, thus lowering long-term opioid dependence.

Evaluation of sex disparities in opioid use among ED patients with sickle cell disease, 2006-2015

BACKGROUND

Acute pain from a vaso-occlusive crisis (VOC) is a leading reason patients with sickle cell disease (SCD) visit the emergency department (ED). Prior studies suggest that women and men receive disparate ED treatment for acute pain in EDs. We aim to determine sex differences in analgesic use among patients with SCD presenting to the ED.

METHODS

This cross-sectional study uses data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2006-2015. We identified ED patients with a primary diagnosis of SCD. Among patients with SCD, we evaluated sex differences in the use of opioid analgesia using logistic regression (adjusting for patient and visit characteristics). Analyses accounted for survey design and weighting.

RESULTS

When evaluating the effect of sex on any opioid medication use in this population, though not significant, the odds that male patients were prescribed opioids was 1.5 (95% CI 0.8-2.8) times that of female patients after adjusting for age, the reason for visit, region, insurance status, and pain score. There was no significant difference in pain scores between male patients, 8.1 (95% CI 7.55-8.68) compared to female patients, 7.4 (95% CI 6.7-8.12).

CONCLUSIONS

In this nationally representative sample of ED visits among patients with SCD, there was no conclusive evidence of sex disparities in opioid prescribing. Though there is evidence of a trend signaling that male patients with SCD were more likely than female patients to be prescribed an opioid.

State Variation in Chronic Opioid Use in Long-Term Care Nursing Home Residents

OBJECTIVE

Policies and regulations on opioid use have evolved from being primarily state-to federally based. We examined the trends and variation in chronic opioid use among states and nursing homes.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

We used the nursing home Minimum Data Set and Medicare claims from 2014 to 2018 and included long-term care nursing home residents from each year who had at least 120 days of consecutive stay.

MEASUREMENTS

Chronic opioid use was defined as use for ≥90 days. Three-level hierarchical logistic regression models (resident, nursing home, state) were constructed to estimate intraclass correlation coefficient (ICC) at the state level and at the nursing home level. The ICC shows the proportion of variation in chronic opioid use that is attributable to states or nursing homes. All models were constructed separately for each calendar year and controlled for resident, nursing home, and state characteristics.

RESULTS

We included 3,245,714 nursing home stays from 2014 to 2018, representing 1,502,131 unique residents. The stays ranged from 676,413 in 2014 to 594,874 in 2018, with residents contributing a maximum of 1 stay per year. Chronic opioid use among nursing home residents declined from 14.1% in 2014 to 11.4% in 2018. The variation (ICC) in chronic opioid use among states declined from 2.5% in 2014 to 1.7% in 2018. In contrast, the variation (ICC) among nursing homes increased from 5.6% in 2014 to 6.5% in 2018.

CONCLUSIONS AND IMPLICATIONS

Variation in chronic opioid use declined by one-third at the state level but not at the nursing home level. National guidelines on opioid use and federal policies on opioid use may have contributed to reducing state-level variation in chronic opioid use.

Relationship Between Pain Management Modality and Return Rates for Lower Back Pain in the Emergency Department

BACKGROUND

Emerging evidence suggests that opioid use for patients with acute low back pain does not improve functional outcomes and contributes to long-term opioid use. Little is known about the impact of opioid administration in the emergency department (ED) for patients with low back pain.

OBJECTIVES

This study compares 30-day return rates after administration of various pain management modalities for emergency department (ED) patients with low back pain.

METHODS

We conducted a retrospective multicenter observational study of patients in the ED who were diagnosed with low back pain and discharged home in 21 EDs between November 2018 and April 2020. Patients were categorized based on the pain management they received in the ED and compared with the reference group of patients receiving only nonsteroidal anti-inflammatory drugs, acetaminophen, or a combination of the two. The proportions of ED return visits within 30 d for each medication category was calculated and associations between analgesia categories and proportions of return visits were assessed using logistic regression models to obtain odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Patients with low back pain who received any opioid, intravenous opioid, or intramuscular opioid had significantly increased proportions of a return visit within 30 d (32% [OR 1.78 {95% CI 1.21-2.64}]; 33% [OR 1.83 {95% CI 1.18-2.86}]; and 39% [OR 2.38 {95% CI 1.35-4.12}], respectively) when compared with patients who received nonsteroidal anti-inflammatory drugs (19%), acetaminophen (20%), or a combination of the two (8%).

CONCLUSIONS

Patients receiving opioids were more likely to return to the ED within 30 d than those receiving received nonsteroidal anti-inflammatory drugs or acetaminophen. This suggests that the use of opioids for low back pain in the ED may not be an effective strategy, and there may be an opportunity to appropriately treat more of these patients with nonopioid medications.

Opioid Prescription Patterns for Discharged Patients from the Emergency Department

Objectives

It is important to analyze the types of etiologies and provider demographics that drive opioid prescription in our emergency departments. Our study aimed to determine which patients in the ED are receiving opioid prescriptions, as well as their strength and quantity. Secondary outcomes included identifying difference in prescribing between provider classes.

Methods

We conducted a retrospective study at a tertiary care university-based, level-one trauma ED from November 2017 to October 2018. We identified and analyzed data from 2,259 patients who were sent home with an opioid prescription. We retrieved patient and provider demographics, diagnosis, etiologies, and prescription information.

Results

The mean age of a patient receiving an opioid prescription was 45, and 72.7% of patients were white. The most common diagnosis groups associated with an opioid prescription were abdominal pain (18.5%), nonfracture extremity pain (18.4%), and back/neck pain (12.5%). Hydrocodone-acetaminophen 5-325 mg was the most commonly prescribed (67.4%). The median total prescribed milligram morphine equivalent (MME) was highest for extremity fracture (75.0; IQR 54.0-100.0). The median total prescribed amount of pills was highest for patients with extremity fractures (15.0; IQR 12.0-20.0).

Conclusions

Our study elucidates the prescribing patterns of an academic level 1 trauma center and should pave the way for future studies looking to maximize effectiveness at ways to curb ED opioid prescription.