Much emphasis has been placed lately on the opioid epidemic in the United States. Physicians, nurse practitioners and physician assistants prescribing opioid medications are often the target of blame for over-prescribing these addictive medications. Research shows that taking opioids for as few as five days may lead to long-term use. The variability in prescription practices can put patients at unnecessary risk for addiction.
The difficulty with guidelines such as those issued by the American Pain Society and the CDC for primary physicians is that they are broad generalizations designed to guide practice and minimize blatant misuse. What many providers desire is to know whether their prescribing practices are appropriate for their patient population and specialty. Efforts have been made to analyze claims data to assess opioid prescribing patterns and develop a standard practice for specific surgical procedures for specific types of patients. Transparency in the number of pills prescribed by like providers can provide context on whether one’s own practices are appropriate. The company Oliver Wyman is developing a tool based on this data that will be marketed with these goals in mind.
One review of opioid prescribing patterns and patient outcomes conducted in Oregon showed that of the nearly 6000 providers included in the study, nurse practitioners (NP) and naturopathic physicians (ND) tended to have patients who received greater proportions of high-dose opioid prescriptions and opioid-related hospitalizations than their MD/DO/PA counterparts. However the patients of these NPs and NDs were more likely to have four or more prescribers, which may be a more important risk factor for over-prescription of opioid medications than the title of the prescriber.
Ultimately, prescribing patterns necessarily differ by practice, specialty, and patient population. It is difficult to make broad recommendations on opioid strength, length of treatment, and frequency of prescription. Comparing practices with other providers to identify outliers in prescribing practices is helpful, as is trialing a reduction of number of pills prescribed to see if patients truly need the current number being prescribed. Prescription pill return programs have been proposed, but they rely heavily on patient education on the importance of returning unused medications. Encouraging use of adjunctive non-opioid medications such as acetaminophen, NSAIDs, gabapentin, and lidocaine patches should be standardized. Combinations of opioids and other synergistic respiratory depressants such as benzodiazepines and sleeping aids should be used cautiously and never newly prescribed at the same time to naïve patients, for such combinations have led to fatalities.
The media attention to the opioid crisis is helpful in changing the culture of prescribers and patients, both in alerting the dangers of opioid over-prescription and overuse, and in creating a new expectation as to how much opiates one should expect to provide. Many surgical procedures do make opioid use appropriate, but the emphasis should be on the lowest strength and shortest duration of treatment possible.
Fink PB, Deyo RA, Hallvik, Hildebran. Opioid Prescribing Patterns and Patient Outcomes by Prescriber Type in the Oregon Prescription Drug Monitoring Program. Pain Med. 2017 Nov 16. doi: 10.1093/pm/pnx283