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http://www.nytimes.com/2017/02/15/health/long-term-opioid-use-doctors-prescriptions.html



Long-Term Opioid Use Could Depend on the Doctor Who First Prescribed It

By JAN HOFFMANFEB. 15, 2017

A man receiving care in an emergency room. Some emergency room doctors are far more likely than others even within their own department to prescribe opioids to treat pain in older people. Credit James Brosher for The New York Times

Some emergency room doctors are far more likely than others even within their own department to prescribe opioids to treat pain in older people, and their patients are at greater risk of using the powerful drugs chronically than those who saw doctors who prescribe them less frequently, according to a large new study.

The research was published Wednesday in The New England Journal of Medicine.

As the opioid epidemic continues to devastate communities around the country, the study was the latest attempt to identify a starting point on the path to excessive use.

“This is the analysis we have been looking for to show the risk of a single exposure of a patient in an emergency room to an opioid,” said Dr. Lewis S. Nelson, the chairman of emergency medicine at Rutgers New Jersey Medical School and University Hospital, who was not involved in the study.

The study tracked about 375,000 Medicare patients with a similar range of complaints in several thousand hospital emergency rooms from 2008 to 2011, as well as the frequency of opioid prescriptions written by the doctors who treated them. It found that the prescribing patterns of whichever physician they encountered was an important factor in their future opioid use.


Over all, researchers estimated that out of every 48 patients who were sent home with a prescription, one would end up using opioids long-term, which researchers defined as at least 180 days of medication over a year. Chronic opioid use, particularly in older people, can contribute to spiraling problems: constipation, confusion, falls and addiction.
But the risk of becoming that patient increased or decreased depending on the treating physician. Researchers found that doctors they identified as “high-intensity” prescribers sent one in four patients home with opioids. “Low-intensity” prescribers gave opioids to one in 14 patients. The patients who saw a high-intensity prescriber were 30 percent more likely to become long-term users, researchers said.

The study’s lead author, Dr. Michael L. Barnett, an assistant professor of health policy and management at Harvard T.H. Chan School of Public Health, said the point of the findings was “not that high-intensity prescribers are necessarily irresponsible in prescribing opioids to certain patients.” But, he said, “Their patients have worse outcomes that we weren’t aware of before.”

Experts in emergency medicine, geriatrics and medical toxicology praised the study.

“It puts the burden on us in the E.R. to be even more thoughtful about how to do things,” said Dr. Nelson, who served on the expert panel for the Centers for Disease Control and Prevention that helped develop opioid guidelines in 2016.

Although researchers looked at the strength and duration of the initial prescription, they did not find that the high-intensity prescribers necessarily prescribed doses that were higher or longer lasting.

Dr. Barnett, a primary care physician at Brigham and Women’s Hospital, said that the critical first step was the decision itself about whether to prescribe opioids, “regardless of how much or how little.”

The disparity in prescribing patterns, he said, demonstrates that “there is no consensus among E.R. doctors who are treating similar patients about when to prescribe opioids and what dose to give, and the lack of guidance for how to treat acute pain.”
More Reporting on Opioids

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“Doctors may have an intuitive sense, but when you rely on intuition, you get inconsistency,” he said. “You get overtreatment and also undertreatment.”

The study did not seek to lay blame for the well-documented rise in opioid use by Medicare patients at the feet of emergency room doctors. Indeed, after patients receive an opioid prescription from the emergency room, they usually have subsequent prescriptions written by doctors outside the hospital, especially primary care physicians. The study’s authors alluded to “clinical inertia” — the belief among follow-up physicians that if the emergency room doctor’s prescription did the trick, they might as well refill it.

Emergency department physicians note that older adults present unique, limiting challenges that further complicate pain management decisions. For any number of events — a twisted ankle, aching gut, or throbbing neck — younger adult patients can often be successfully treated with anti-inflammatory drugs, such as naproxen or ibuprofen, and an ice pack.
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But Dr. Michael A. Steinman, a professor of medicine at the University of California, San Francisco School of Medicine, who has studied the increase of opioid use among older adults, said that these commonly used medications can exacerbate kidney and blood pressure problems for them, and raise

the risk of stomach ulcers, particularly if used long term.

“So for many types of pain we’re left with creams, salves, patches and Tylenol,” said Dr. Steinman, a geriatrician. “And after that, you’re up to opioids. We have few medication options.”

Certainly many cases warrant opioids, he said, such as a broken bone. “But a sprained ankle? A painful rash? We shouldn’t just routinely recommend an opioid because someone is in pain.”

But he also noted that there is a “structural disincentive” to offer alternatives to medication, such as acupuncture, massage therapy, physical therapy, because of poor insurance reimbursement.

Another point from the study, said Dr. Maryann E. Amirshahi, an emergency room physician at Medstar Washington Hospital Center who has a background in pharmacology and addiction medicine, was that if doctors were going to consider prescribing opioids, pausing a few moments in their harried shift was in order.

“We should be more mindful,” she said, recommending that doctors ask risk-assessment questions, prescribe shorter courses and err on the side of not having leftover, “just-in-case” pills.

Also important, she said: “Talking with patients about the role of opioids.”

Recently, Dr. Barnett, the lead author, realized himself that to do so amounted to a modest but meaningful shift in routine practice. He saw a patient who had first been treated in the emergency department for pain and bruising after falling on her back down winter-slick steps.

“She was in enormous pain and had such difficulty moving around that I felt I had no choice but to give her a short prescription of opioids to get through the weekend, just to be functional,” he recalled. “I told her about the risks of constipation and sleepiness. But I didn’t tell her about dependence and addiction.

“And that’s one lesson from this paper. Doctors don’t even know what they’re doing is a habit. We have to decide to interrupt ourselves, like picking up a backpack with your other arm: ‘Oh, I need to tell this patient about another risk with this medication.’ ”