Author affiliations:
1Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
2Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
3Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
Physicians were more likely to prescribe opioids later in the day and when appointments were running behind schedule.
After seeing dozens of patients in a hectic and long day in the clinic, when a doctor is faced with another patient in pain, it may be easiest to prescribe opioids and move on to the next one. New research suggests that doctors who practice with this habit could be contributing to the opioid epidemic.
A study published in JAMA Network Open on Friday reveals that physicians were more likely to prescribe opioids later in the day and when appointments were running behind schedule.
“Physicians play a crucial role in the opioid epidemic and it’s important to find the factors that drive decisions to prescribe opioids,” said Hannah Neprash, an assistant professor of health policy and management at the University of Minnesota and the study’s lead investigator. “Many studies have looked at looked at differences in prescribing patterns between physicians but few have looked at variation within physicians.”
The study utilized claims and electronic health data in 2017 for 678,319 patients with new pain who saw 5,603 physicians at health care clinics. The patients’ complaints ranged from back pain and headaches to muscle and joint aches. The researchers looked at the order of appointments and whether an appointment started at its scheduled time. Opioid prescriptions were compared to prescriptions of non-steroidal anti-inflammatory drugs and physical therapy.
When working with patients in pain who want opioids, offering them alternative therapies such as NSAIDs or physical therapy can require time-consuming discussions, Neprash said. “Prescribing opioids may be the quick fix when they do not have enough time to discuss non-opioid options.”
In 2017 there was six times the number of opioid-related deaths compared to 1999. While much of the opioid epidemic is due to illicit drug use, prescription opioids still play a large role. The authors note that if prescribing practices remained constant throughout the day, 4,459 opioid prescriptions would not have been written in 2017.
The study draws attention to demands placed on doctors who are incentivized to see as many patients as possible. The authors recommend protocols to guard against physician fatigue, arguing that if time pressures are affecting opioid prescriptions, other major medical decisions could also be at risk.
This should come as no surprise to a clinician. Pain is bad, and immediate relief is wanted by the patient and physician. Prescribing a pill gratifies both doctor and patient rewarding the encounter clinically, and gratifying a fee for service (pain relief). In today's medical environment satisfaction surveys are supreme. Health insurance companies and plans regularly survey patient's satisfaction quotients based on many subjective metrics.
Dr. Mark Linzer, director of the Office of Professional Worklife at Hennepin Healthcare in Minneapolis, said adding more clinical team members, such as physician assistants and nurse practitioners, could help diffuse the workload of the day and allow clinicians to spend more time with patients. He also proposed making individual visits longer for certain patients in order to provide the time needed to address pain and other sensitive medical problems.
“I suspect this is the tip of the iceberg: that time pressure has numerous adverse consequences, and that these poor outcomes could be attenuated by providing the time that complex patients (including those with acute and chronic pain) need with their clinicians,” said Linzer, who was not involved in the study.
“The conversation that avoids narcotics just takes time,” he said
Was the doctor on time?
Was the staff courteous?
Are you satisfied with the results of your encounter?
How long did you have to wait?
Would you recommend this doctor to a friend or family member?
None of these questions ask for an objective response. None of them are measuring the real quality of care (ie, clinician accuracy). In most cases, patients are incompetent in assessing their doctor's clinical competence.
Worse than that are newer measures of supposed physician competence, MOC (maintenance of competence) (taken five to ten years after initial board certification). Many insurers now list whether a doctor is maintaining MOCs. These tests and certifications reveal no correlation of results, patient satisfaction, nor a reduction in medico-legal events. It may set a totally irrelevant and inaccurate measure of physician quality of care.
Doctors more likely to prescribe opioids later in the day — or if running late:
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