Variability in emergency physician decisionmaking about prescribing opioid analgesics

Tamayo-Sarver, Joshua H.; Dawson, Neal V.; Cydulka, Rita K.; Wigton, Robert S.; Baker, David W.

doi:10.1016/j.annemergmed.2003.10.043

Cited by 131 publications

(66 citation statements)

References 23 publications

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“…Furthermore, a study involving physicians who faced criminal prosecution or charges by medical boards for inappropriate opioid prescribing practices between 1998 and 2006 found that 39% were either general practitioners or family physicians, relative to 4% who were either self-identified or board certified as pain specialists (23). The lack of conclusive research in this area has led one set of investigators to conclude that opioid prescribing practices are idiosyncratic and based largely on providers' personal beliefs regarding their appropriateness (24). It appears to be reasonable to suspect that these beliefs may cluster according to specialty due, in part, to the varying patient populations served by each.…”

Section: La Prescription Différentielle D'analgésiques Opioïdes En Fomentioning

confidence: 99%

Differential Prescribing of Opioid Analgesics According to Physician Specialty for Medicaid Patients with Chronic Noncancer Pain Diagnoses

Ringwalt

Gugelmann

Garrettson

et al. 2014

Pain Research and Management

139

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P ain constitutes one of the most prevalent diagnoses in primary care settings (1), and is the complaint presented by nearly two-thirds of emergency department patients treated in the United States (US) (2). Estimates of the prevalence of all chronic pain in the US population range considerably, from 8% to 48%, depending on the stringency of the definitions used. One recent review offered a weighted estimate of 22% (3); a somewhat more dated review provided an estimate of 15% (4). Opioid analgesics are the mainstay for pharmacological treatment for moderate to severe pain and have improved the quality of life for many (5-7). However, in the first decade of the 21st century, the amount of prescription analgesics, such as fentanyl, hydrocodone, methadone, oxymorphone and oxycodone, increased by a factor of four (8), and deaths due to the abuse and misuse of such analgesics nearly doubled (9). In 2009, poisoning deaths became the leading cause of injury-related death in the US (10).The BACkgRouND: Despite >20 years of studies investigating the characteristics of patients seeking or receiving opioid analgesics, research characterizing factors associated with physicians' opioid prescribing practices has been inconclusive, and the role of practitioner specialty in opioid prescribing practices remains largely unknown. oBjECTIvE: To examine the relationships between physicians' and other providers' primary specialties and their opioid prescribing practices among patients with chronic noncancer pain (CNCP). METHoDS: Prescriptions for opioids filled by 81,459 Medicaid patients with CNCP in North Carolina (USA), 18 to 64 years of age, enrolled at any point during a one-year study period were examined. χ 2 statistics were used to examine bivariate differences in prescribing practices according to specialty. For multivariable analyses, maximum-likelihood logistic regression models were used to examine the effect of specialty on prescribing practices, controlling for patients' pain diagnoses and demographic characteristics. RESuLTS: Of prescriptions filled by patients with CNCP, who constituted 6.4% of the total sample of 1.28 million individuals, 12.0% were for opioids. General practitioner/family medicine specialists and internists were least likely to prescribe opioids, and orthopedists were most likely. Across specialties, men were more likely to receive opioids than women, as were white individuals relative to other races/ethnicities. In multivariate analyses, all specialties except internal medicine had higher odds of prescribing an opioid than general practitioners: orthopedists, OR 7.1 (95% CI 6.7 to 7.5); dentists, OR 3.5 (95% CI 3.3 to 3.6); and emergency medicine physicians, OR 2.7 (95% CI 2.6 to 2.8). CoNCLuSIoNS: Significant differences in opioid prescribing practices across prescriber specialties may be reflective of differing norms concerning the appropriateness of opioids for the control of chronic pain. If so, sharing these norms across specialties may improve the care of patients with CNCP.

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Section: La Prescription Différentielle D'analgésiques Opioïdes En Fomentioning

confidence: 99%

Differential Prescribing of Opioid Analgesics According to Physician Specialty for Medicaid Patients with Chronic Noncancer Pain Diagnoses

Ringwalt

Gugelmann

Garrettson

et al. 2014

Pain Research and Management

139

View full text Add to dashboard Cite

show abstract

“…One study showed that when faced with identical hypothetical case scenarios, ED physicians' decisions whether to prescribe an OA varied greatly [14]. For the same clinical scenario, subtle differences in the patient-doctor interaction (for example, a patient requesting a specific drug or an additional dose of pain medication) could change the likelihood of prescribing substantially [18]. To support this unconscious bias, Pomerleau, et al uncovered some interesting paradoxes.…”

mentioning

confidence: 99%

Opioid Prescribing: How Well Do We Know Ourselves?

Wightman

Nelson

2016

J. Med. Toxicol.

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Get your facts first, then you can distort them as you please.-Mark Twain BI would rather over-prescribe and risk some medication diversion or non-medical use, than under-prescribe and not treat a patient's pain.^This statement, taken from a survey published in the current issue of JMT by Pomerleau et al. 2016 [1], was used to assess clinicians' self-reported attitude about the challenge in meeting individual patient needs while balancing public health risk. The statement essentially pinpoints the current dilemma in the ED: alleviation of suffering in an individual may expose that patient or others (through misuse or diversion) to the risk of opioid analgesic (OA) abuse, addiction, overdose, and death. Pain-related complaints are the most common reason for Emergency Department (ED) visits [2,3], and ED providers are among the top five medical specialist groups writing prescriptions for OAs in patients under 40 years of age [4]. However, only 17 % of ED patients are given a prescription for an OA on discharge and the majority of prescriptions dispensed are for a small number of immediate release pills [5,6]. Still, iatrogenic opioid abuse and addiction remain a concern, because half of ED patients with opioid-use disorders were first exposed to an opioid by a prescription from a medical provider [7].Responsible opioid analgesic prescribing is paramount in our efforts to combat the epidemic of opioid abuse and promote safe opioid use, but little is currently known about which factors drive decision-making among emergency department (ED) prescribers of OAs. Pomerleau et al. highlights the complexity of the decision-making process and brings forth a number of interesting issues. Through a series of queries, the study explores the factors providers believe affect their OA prescribing practices, as well as their attitudes toward OA prescribing. Of course, individual provider opinions and attitudes cannot provide the complete picture. Patient age, race, type of insurance, provider training and experience, functionality of PDMPs, and geographic location are a few of the many factors highlighted in the literature to affect OA prescribing decisions.Whether to prescribe an OA for any given patient not only depends on the aforementioned patient and provider factors and the culture of the work environment, but also on the quality and type of patient doctor communication. One study showed that when faced with identical hypothetical case scenarios, ED physicians' decisions whether to prescribe an OA varied greatly [14]. For the same clinical scenario, subtle differences in the patient-doctor interaction (for example, a patient requesting a specific drug or an additional dose of pain medication) could change the likelihood of prescribing substantially [18]. To support this unconscious bias, Pomerleau, et al. uncovered some interesting paradoxes. For example, survey respondents report that they would be less likely to write a prescription for a patient with an opioid use disorder, but they also state their skills to identify pat...

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“…The study included a large sample size of supervisors from a range of industrial sectors, a conceptual framework for the identification of predictors, and validated measurement instruments. The use of case vignettes is a well-established research method for studying the decision-making practices surrounding health and functional problems [25][26][27]. The case vignettes allowed us to test a number of hypothesized variables thought to influence decision-making, and allowed predictive variables to include both experimental factors (randomized factors systematically altered in different versions of the vignette), and respondent factors (variables reflecting attitudes and characteristics of the decision maker).…”

Section: Discussionmentioning

confidence: 99%

“…Such studies have shown relatively poor adherence to evidencebased guidelines for the treatment of acute LBP among physicians, especially among general practitioners with more years of clinical experience. Other case vignette studies in medical research have focused on the professional judgments of social workers regarding the need for institutional care [26], the opioid prescribing practices of emergency room physicians [27], and the effect of racial bias in medical decision-making [28]. Case vignettes can test a number of hypothesized variables thought to influence decision-making, and predictive variables can include both experimental factors (randomized factors systematically altered in different versions of the vignette), and respondent factors (variables reflecting attitudes and characteristics of the decision-maker).…”

Section: Methodsmentioning

confidence: 99%

Supervisor and Organizational Factors Associated with Supervisor Support of Job Accommodations for Low Back Injured Workers

et al. 2016

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PURPOSE-Temporary job accommodations contribute to the prevention of chronic work disability due to low back pain (LBP) through the facilitation of early return to work; yet, workplace dimensions of job accommodation are poorly understood. The objective of this study was to determine supervisor and organizational factors associated with supervisors' support for temporary job accommodations for LBP injured workers. METHODS-Supervisorswere recruited from 19 workplaces in the USA and Canada and completed an online survey regarding job accommodation practices and potential associated factors with respect to a case vignette of a worker with LBP. Multivariable linear regression was used to identify the most parsimonious set of factors associated with supervisors' support for accommodations. RESULTS-

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Variability in emergency physician decisionmaking about prescribing opioid analgesics

Cited by 131 publications

References 23 publications

Differential Prescribing of Opioid Analgesics According to Physician Specialty for Medicaid Patients with Chronic Noncancer Pain Diagnoses

Differential Prescribing of Opioid Analgesics According to Physician Specialty for Medicaid Patients with Chronic Noncancer Pain Diagnoses

Opioid Prescribing: How Well Do We Know Ourselves?

Supervisor and Organizational Factors Associated with Supervisor Support of Job Accommodations for Low Back Injured Workers

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