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Emergency Physicians Prescribe Few Opioids Compared to Some Specialties

STANFORD, CA – Emergency physicians sometimes are accused of being among the worst offenders for over-prescribing painkillers and contributing to the opioid overdose epidemic.

A new study suggests that really isn’t true.

The research letter in JAMA Internal Medicine notes that, while prescriptions for opioid pain relievers often were concentrated in specialties for pain, anesthesia, and physical medicine and rehabilitation, general practitioners dominated total prescriptions among Medicare prescribers based on volume.

The study team, led by Stanford University researchers, used prescription drug coverage claims in the 2013 Medicare Part D claims data set to examine data from individual prescribers, including physicians, nurse practitioners, physician assistants and dentists.

With the data representing more than 1.1 billion claims costing nearly $81 billion, researchers zeroed in on opioid prescriptions containing hydrocodone, oxycodone, fentanyl, morphine, methadone, hydromorphone, oxymorphone, meperidine, codeine, opium or levorphanol.

Claims by provider type were 1124.5 for interventional pain management and 921.1 for pain management on a logarithmic scale. On that scale, family practice was at 161.1, representing 15,312,092 claims, and internal medicine at 122 with 12,785,839 claims. Emergency medicine was at a relatively low 51, with 1,767,183 total claims that year.

"The bulk of opioid prescriptions are distributed by the large population of general practitioners," said lead author Jonathan Chen, MD, PhD.

When they looked at prescriber types, opioid prescriptions were most concentrated in interventional pain management, pain management, anesthesiology and physical medicine and rehabilitation specialties.

“Contrary to the California Worker’s Compensation data showing a small subset of prescribers accounting for a disproportionately large percentage of opioid prescribing, Medicare opioid prescribing is distributed across many prescribers and is, if anything, less skewed than all drug prescribing,” according to the study. “The trends hold up across state lines, with negligible geographic variability.”

Researchers note a skewing for total drug costs of Medicare opioid claims, however, with 78% accounted for by 10% of prescribers, noting, “This could be selection of more expensive formulations or higher doses prescribed.”

“High-volume prescribers are not alone responsible for the high national volume of opioid prescriptions, the authors conclude. “Efforts to curtail national opioid overprescribing must address a broad swath of prescribers to be effective.”

“Being a physician myself, I am acutely aware of the emotional angst that can occur when deciding whether to prescribe opioids to a patient who may have simultaneously developed a chronic-pain and substance-dependence problem,” Chen said in a Stanford University press release. “The public health epidemic of opioid overuse is perhaps not surprising given the tenfold increase in volume over the past 20 years."

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