Numerous factors influence the opioid crisis in healthcare in the UK, US and worldwide, including the lack of recommendations or referrals toward holistic treatments and other alternative therapies for acute, but most of all for chronic pain relief in mainstream medicine.
But the authors of a recent study on opioid use and found another startling factor that might be adding to the ever increasing opioid crisis: the increasing rate of opioid prescribing.
Hannah Neprash, an assistant professor at the University of Minnesota and Michael Barnett, an internal medicine specialist practicing in multiple hospitals around Boston, found that physicians are more likely to prescribe opioids as their shift progresses and appointments fall behind schedule when Doctors are to talk to the patient, assess or examine them and refer them to other specialties or prescribe medications in a 10-15 minute window.
Their study, published in JAMA Network Open, also hinted at the possible factors behind this unsettling trend, including burnout, fatigue and time pressure. Further studies assessing these factors in detail might help shed light on the thought process that leads to prescribing opioids, the authors added.
Time & Lateness Affect clinical Decision-Making
To assess trends in opioid prescribing, Neprash and Barnett examined 678,319 appointments in 2017. The appointments involved 642,262 patients and 5,603 primary care physicians (GP’s).
The patients had gone to their Doctor to discuss painful conditions. Neprash and Barnett grouped these into five categories, namely headache, back pain, joint disease, musculoskeletal conditions and painful conditions/syndromes. None of them had been taking opioids or had been prescribed opioids in the last 12 months prior to their appointment in which this study oversaw.
The duo also grouped the appointments into sets of three and studied just a maximum of 21 appointments for each given day. They also gathered information regarding the timeliness of the appointments in 10-15 minute increments.
Upon assessing these data sets, Neprash and Barnett found that timing and lateness had a significant impact on a patient’s chances of being prescribed opioids. For instance, it appeared that Doctors prescribed opioids just 4% of the time during their first three appointments, however this changes when Doctors are left dealing with patients who have complex cases or present with emergency symptoms such as chest pain or shortness of breath.
But during their 19th to 21st appointments, physicians prescribed opioids 5.3% of the time. This corresponds to a 33% increase in the likelihood of opioid prescribing. The sudden jump also confirmed Neprash and Barnett’s hypothesis that appointment timing affected clinical decision-making.
The True Effect Of Lateness On Patient Outcomes
The duo noted that although 5.3% doesn’t seem like a big number, this corresponds to 4,459 more opioid prescriptions that could have been avoided if the Doctor wasn’t running behind or had a slightly longer appointment time.
Neprash and Barnett found similar but smaller results after assessing the impact of lateness in clinical decision-making. It appeared that 4.4% of appointments running zero to nine minutes late resulted in an opioid prescription.
On the other hand, 5.2% of appointments that ran at least an hour late resulted in an opioid prescription. This corresponds to a 17% increase.
For comparison, the duo also assessed trends in the prescribing of non-steroidal painkillers (NSAID’s) and referrals to physical therapy or other routes for treatment using the same time and lateness metrics. They found no similar or apparent patterns, thus suggesting that the patterns detailed earlier might be unique to opioid prescriptions.
Based on their results, Neprash and Barnett concluded that clinical decision-making for opioid prescribing is influenced by the timing and lateness of appointments.
These findings could help researchers understand the role of appointment timing and other possible factors influencing clinical decision-making, such as burnout and fatigue, in the opioid crisis, the authors noted.
These findings, therefore, help shed light on this problem.
That being said, it did stop short of recommending that hospitals should make changes to their opioid programs. This might be something that future studies can look into, he added.
Prof Michael Ellenbogen
According to Michael Ellenbogen, an assistant professor of medicine at John Hopkins University‘s School of Medicine, Neprash and Barnett’s findings offer empirical evidence that physicians are prescribing opioids to patients complaining of pain as a sort of shortcut if pressed for time.
It’s Not Limited To The NHS In The UK
It’s not limited to hospitals and doctors surgeries in the UK that show the same issues. Findings from other research papers show similar outcomes worldwide. For example, the article entitled “Pressured to prescribe” The impact of economic and regulatory factors on South-Eastern ED physicians when managing the drug seeking patient also shows that a similar effect is exhibited by Doctor’s in emergency departments.
Thing’s Won’t Change Until We Have A Unified Consensus
I was a paramedic for over 10 years, experiencing chronic pain issues for years on end. I’d visit my GP to get help and I’d constantly be prescribed some form of opioid based medication. After about a year or so, I became physically dependent upon them which then led me to begin injecting heroin when my GP stopped the prescription abruptly overnight without even tapering the dose.
I honestly believe that if I had slightly longer appointments, that it may have been avoided by seeking alternatives with other less addictive medications or referrals to specialists like pain management teams. I now have had to quit the job I loved and adored, simply because of a few small tablets that I took daily.
A. Reader – Wales
However, we aren’t likely to make patient oriented change until we all have one goal, one patient-centred plan to overcome this issue in order to reduce the amount of addicts that have been and will become addicted to prescribed opioids in the future.
Whether it be by increasing appointment times for patients with chronic/complex pain issues, or easier access or the ability to self refer to specialists such as pain clinics, we aren’t going to make effective change.
However we aren’t even having the discussion at the moment surrounding this issue and we hope that this piece of research, and others will prompt government’s worldwide to at least begin the debate about topics like this one.
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