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 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.
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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."
SOURCE: http://bit.ly/2l1Vtzr New England Journal of Medicine,
online February 15, 2017.
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