Wide variation in willingness of ER doctors to prescribe painkillers

A national comparison of emergency room physicians has uncovered a broad range of prescribing patterns for painkillers, and high-volume prescribers may be encouraging long-term use of the drugs among their elderly patients.

Based on medical histories of more than 377,000 Medicare recipients, researchers found that doctors considered frequent prescribers were 300 percent more likely to give out prescriptions for painkillers than low-volume physicians in the same hospital, and those heavy-prescribers were 30 percent more likely to give their patients prescriptions for longer periods.

Yet their patients were only 3 percent more likely to show up at the hospital to be treated for a long-term drug problem, compared with the patients of doctors who were more restrained in their prescribing habits.

"These results suggest that an increased likelihood of receiving an opioid for even one encounter could drive clinically significant future long-term opioid use and potentially increased adverse outcomes among the elderly," the research team writes in the New England Journal of Medicine.

But it's not clear "whether this variation reflects overprescription by some prescribers and whether it is amenable to intervention," they conclude.

A 3 percent increase in hospitalization for opioid problems "isn't necessarily a large volume, but a little bit of a lot is still going to be a lot" which is why an increase in risk for the elderly is a reason for concern, said Dr. Evan Schwarz of Washington University School of Medicine in St. Louis, who was not involved in the research.

"To us, I think it's a bigger effect than it seems," lead study author Dr. Michael Barnett of the Harvard T.H. Chan School of Public Health in Boston told Reuters Health. "These are elderly folks who are coming to the emergency room who haven't been using opiates at all. This is not a high-risk population. We expect low rates."

Among elderly Medicare patients, opioid overdoses quadrupled from 1993 to 2012. Not only does excessive opioid use spark addiction in this group, it increases their likelihood of deadly falls.

Whether the rates are increasing because doctors have become too quick to prescribe the drugs is a matter for debate, particularly when doctors often have little guidance for how to best use them.

"It's not like there's one approach that's going to magically not overtreat or not undertreat pain. It's hard," Barnett said. "But I think right now it's really a Wild West of guesswork in terms of how we make decisions."

The study focused on emergency room physicians because patients coming into the ER usually don't know who will be treating them, and the researchers looked at Medicare records from 2008 to 2011.

Among the "high-intensity" prescribers (who gave out the drugs to 24.1 percent of their patients), the rate of long-term opioid use - for six months or more - in their patients was 1.51 percent.

In comparison, among "low-intensity" prescribers (who were giving out opioid prescriptions to 7.3 percent of their patients), the rate was 1.16 percent.

The patients given more drugs were only 3 percent more likely to show up at a hospital within 12 months with an opioid-related drug problem, but the rates were high in both groups - 9.96 percent with high-prescribing doctors versus 9.73 percent with low-prescribing physicians.

The odds of a hospital visit for a fall or fracture were also significantly higher for the patients of high-prescribing doctors, but not spectacularly so.

"The thing this study doesn't tell us is, was the prescription appropriate or why the high-volume providers are providing prescriptions," said Schwarz. "We don't want to assume that all of this is inappropriate."

Both Schwarz and Barnett noted that the problem of overprescribing may be lessening.

"These data are coming from the peak of opioid prescribing because I think we've started to see a downturn, starting in 2015 or so," Schwarz said. "It may mean the pendulum is slowly starting to swing back in the other direction."

Contributing to the problem, he said, is the fact that "doctors frequently don't tell patients that opioids have a risk of developing some kind of dependence or chronic use. Many people might take a second look at whether they really want that prescription if the doctor actually told them about that risk."