“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.
Overall, physicians were 33% more likely to prescribe opioids later in the day and 17% more likely to do so if the appointment was running later than its scheduled time. NSAIDs and physical therapy prescribing did not change throughout the day.
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 were 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.
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.