The opioid epidemic has been widely covered in the media and has drawn the attention of lawmakers and the medical community. Physicians, physician assistants, nurse practitioners, and other medical providers responsible for prescribing opiate medications are often the subject of scrutiny as to their prescribing practices. In some studies, taking opioids for as few as five days may increase the risk of long-term use. Variability in providers’ prescribing patterns results in some patients receiving more opiate medications than needed, creating potential for diversion and addiction.
Guidelines have been issued by such groups as the CDC (with their recent opioid prescribing guidelines for primary care physicians) and the American Pain Society to address this issue. However they are largely broad and non-specific, designed to minimize blatant wrongdoing and provide guidance that is inclusive of most patient populations. It is difficult to make more specific recommendations on exactly how much opioid medication providers should be prescribing, as this necessarily differs from patient population, specialty, and if applicable, surgical procedure.
Efforts are being made by companies such as Oliver Wyman to create tools based on claims analysis of opioid prescribing patterns to provide a more specific standard practice model. These tools would be designed to be specific to surgical procedure and patient characteristic, so that an orthopedic surgeon may see what kind of opiates and how many pills his colleagues are prescribing healthy joint replacements, for example. Creating standard practice patterns and providing providers with transparency on these patterns facilitates identification of outliers, with those prescribing more than the standard potentially examining whether scaling back on strength or duration of treatment is prudent, and those under-prescribing offering the community insights on what characteristics of their practice allow for them to do so.
Specific prescribing patterns of mid-level providers have been studied, with one review of nearly 6000 providers in Oregon showing that 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, these patients were also more likely to have four or more opioid prescribers, suggesting that the number of prescribers is a more salient risk factor than the title of individual providers.
Ultimately, each practice and provider must determine how best to prescribe opioid medications responsibly. Comparing standard patterns with other providers is helpful, as is trialing a reduction of number or strength of pills prescribed to see if patients truly need the supply they are given. Some practices employ pill return programs, and with the increasing media attention on the opioid crisis these may be more successful as patient buy-in increases. Adjunctive medications such as acetaminophen, NSAIDs, and gabapentin should be routinely prescribed unless contraindicated. Extreme caution must be taken when combining opioids, benzodiazepines and sleeping aids, as such cocktails may have synergistic effects on respiratory depression, sometimes leading to fatalities.
References
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
https://www.statnews.com/2017/08/24/opioid-prescribing-doctors/
