Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use

Abstract

Background: Increasing overuse of opioids in the United States may be driven in part by physician prescribing. However, the extent to which individual physicians vary in opioid prescribing and the implications of that variation for long-term opioid use and adverse outcomes in patients are unknown.

Methods: We performed a retrospective analysis involving Medicare beneficiaries who had an index emergency department visit in the period from 2008 through 2011 and had not received prescriptions for opioids within 6 months before that visit. After identifying the emergency physicians within a hospital who cared for the patients, we categorized the physicians as being high-intensity or low-intensity opioid prescribers according to relative quartiles of prescribing rates within the same hospital. We compared rates of long-term opioid use, defined as 6 months of days supplied, in the 12 months after a visit to the emergency department among patients treated by high-intensity or low-intensity prescribers, with adjustment for patient characteristics.

Results: Our sample consisted of 215,678 patients who received treatment from low-intensity prescribers and 161,951 patients who received treatment from high-intensity prescribers. Patient characteristics, including diagnoses in the emergency department, were similar in the two treatment groups. Within individual hospitals, rates of opioid prescribing varied widely between low-intensity and high-intensity prescribers (7.3% vs. 24.1%). Long-term opioid use was significantly higher among patients treated by high-intensity prescribers than among patients treated by low-intensity prescribers (adjusted odds ratio, 1.30; 95% confidence interval, 1.23 to 1.37; P<0.001); these findings were consistent across multiple sensitivity analyses.

Conclusions: Wide variation in rates of opioid prescribing existed among physicians practicing within the same emergency department, and rates of long-term opioid use were increased among patients who had not previously received opioids and received treatment from high-intensity opioid prescribers. (Funded by the National Institutes of Health.).

Figure 1. Prescribing Rates and Adjusted Odds Ratios for Long-Term Opioid Use, According to Quartile of Physician Opioid Prescribing

Panel A shows rates of opioid prescribing by emergency physicians according to within-hospital quartile. I bars represent 95% confidence intervals. Panel B shows the adjusted odds ratios and corresponding 95% confidence intervals for rates of long-term opioid use, according to quartile of physician opioid prescribing. Physicians in each quartile were compared with those in the lowest prescribing quartile. Odds ratios were estimated with the use of logistic-regression models.

Figure 2. Unadjusted and Adjusted Odds Ratios for Long-Term Opioid Use, According to Treatment by High-Intensity or Low-Intensity Opioid Prescriber

All unadjusted odds ratios were estimated with the use of bivariate logistic regression with the occurrence of long-term opioid use as the dependent variable and exposure to a high-intensity provider as the key explanatory variable. All adjusted models had further adjustment for the patients’ age, sex, race or ethnic group, Medicare–Medicaid dual eligibility, and disability status and the presence of 11 chronic conditions.