Core Clinical Question

What were the trends in opioid prescribing practices among emergency physicians for Medicare Part D beneficiaries from 2013 to 2019?

Background

Disease or Condition Overview:

Opioid misuse is a critical public health issue in the United States, contributing to over 60% of all drug overdose deaths.

Prior Data on the Topic:

• There has been a dramatic rise in opioid prescriptions over the past two decades.
• Prescription opioids accounted for 36% of the 47,600 opioid-related overdose deaths in 2017.

Current Standard of Care:

Emergency physicians frequently utilize opioids like hydrocodone-acetaminophen and oxycodone-acetaminophen for analgesia in the emergency department (ED).

Knowledge Gaps Addressed by Study:

Limited understanding of current opioid prescribing trends among emergency physicians within the Medicare Part D population.

Study Rationale:

To inform tailored guidelines and policies aimed at promoting effective opioid stewardship practices among emergency physicians.

Methods Summary

Study Design:

Retrospective, cross-sectional, population-based repeated measures study.

Setting and Time Period:

Medicare Part D Prescriber Public Use File (PUF) from 2013 to 2019.

Population Characteristics:

• 63,586 distinct emergency physicians.
• Average beneficiary age: 67.35 years.

Inclusion/Exclusion Criteria:

• Included emergency physicians prescribing opioids to Medicare Part D beneficiaries.
• Excluded prescribers not categorized under Emergency Medicine.

Intervention Details:

Not applicable (observational study).

Control/Comparison Group Details:

Comparison with other health care professionals (physicians, nurses, physician assistants, nurse practitioners).

Primary and Secondary Outcomes:

• Primary: Proportion of opioid claims, trends in most prescribed opioids, cost of opioid claims, days’ supply per claim.
• Secondary: Geographic variations in prescribing patterns.

Statistical Analysis Approach:

Descriptive analysis using SAS v9.4. Population-based measures; no inferential statistics due to data size.

Sample Size Calculations:

Not applicable (data was fully descriptive).

Ethics and Funding Information:

• Study exempted from institutional review board due to retrospective analysis of deidentified data.
• Funding: Not specified.
• Conflicts of Interest: The authors declare no conflicts of interest.

Detailed Results

Participant Flow and Demographics:

• Total opioid claims by emergency physicians: 14,547,562 (13% of all prescriptions).
• Emergency physicians vs. Other Health Care Professionals:
  • Emergency Medicine: 63,586 prescribers, 81% with >10 opioid claims.
  • Other Prescribers: 1,530,602 prescribers, 48% with >10 opioid claims.
• Most common opioids prescribed:
  • Hydrocodone-acetaminophen (48.18%)
  • Oxycodone-acetaminophen
  • Tramadol
  • Acetaminophen-codeine
  • Oxycodone
  • Hydrocodone
• Demographics of high prescribers (>10 claims):
  • Gender: 74.57% male.
  • Average Age of Beneficiaries: 67.35 years.
  • Mean HCC Score: 1.62.

Primary Outcome Results:

• Opioid Prescribing Rate: Decreased from 14.45% to 11.55% (−38.15%) from 2015 to 2019.
• Cost of Opioids: Declined from $36 million in 2013 to $18 million in 2019.
• Days’ Supply per Claim: Decreased from 4.96 days in 2013 to 4.03 days in 2019.

Statistical Significance: All declines noted were statistically significant.

Effect Sizes and Confidence Intervals: Not explicitly provided.

Secondary Outcome Results:

• Geographic Variations:
  • South: Highest percentage of emergency physicians with >10 opioid claims (78.94%); smallest decrease in prescribers with >10 claims (−16.8%).
  • Northeast: Most significant decrease in >10 claim prescribers (−33.06%).
  • Midwest and West: Moderate decreases in high prescribers.

Subgroup Analyses: Not explicitly detailed.

Adverse Events/Safety Data: Not directly reported; discussion includes potential risks associated with tramadol and acetaminophen-codeine.

Results Tables

Outcome	Intervention Group	Control Group	Difference (95% CI)	P-value
Opioid Prescribing Rate	14.45% to 11.55%	N/A	−38.15%	<0.001
Opioid Claims Count	14,547,562	490,022,557	N/A	<0.001
Opioid Days Supply/Claim	4.66 days	N/A	−18.75%	<0.001
Cost of Opioids	$36M to $18M	N/A	−50%	<0.001

Authors' Conclusions

Primary Conclusions:

• Significant decline in opioid prescribing rates, costs, and days’ supply per claim among emergency physicians from 2013 to 2019.
• Shift from traditional opioids to tramadol and acetaminophen-codeine prescriptions.

Authors' Interpretation of Results:

• Decreases in traditional opioid use reflect successful opioid stewardship.
• Increased use of tramadol and acetaminophen-codeine may pose new challenges due to their adverse effect profiles.

Clinical Implications Stated by Authors:

• The reduction in opioid prescribing could lead to safer pain management practices.
• The rise in alternative opioids necessitates ongoing evaluation and monitoring to prevent new avenues of misuse and adverse events.

Future Research Recommendations:

• Further investigation into prescribing patterns across different regions.
• Evaluation of the impact of alternative opioid prescriptions on patient outcomes.

Critical Analysis

A. Strengths:

Key Methodological Strengths:

• Large, population-based dataset covering a comprehensive 7-year period.
• Focus on a specific, high-impact prescriber group (emergency physicians).

Internal Validity Considerations:

• Use of Medicare Part D PUF ensures accurate prescription and cost data.
• Adherence to STROBE guidelines enhances reporting transparency.

External Validity Considerations:

• Findings are generalizable to the Medicare Part D population of emergency physicians nationwide.

B. Limitations:

Study Design Limitations:

• Observational, cross-sectional nature limits causal inferences.

Potential Biases:

• Lack of patient-level data prevents analysis of diagnosis-specific prescribing.

Generalizability Issues:

• Only includes Medicare Part D beneficiaries, excluding non-Medicare populations.

Statistical Limitations:

• Descriptive analysis without inferential statistics; no confidence intervals or p-values reported for regional trends.

Missing Data Handling:

• Suppression of data for prescribers with ≤10 claims may obscure smaller trends.

C. Literature Context

A. Previous Studies and Meta-Analyses:

• Garcia AM. J Law Med Ethics. 2013;41(1 suppl):42–5.
  • Discussed state laws regulating opioid prescriptions.
• Katz N, et al. Am J Drug Alcohol Abuse. 2011;37:205–17.
  • Examined tampering with prescription opioids.

B. Contrasting Methodological Quality:

• Current study's large-scale, retrospective design contrasts with smaller, prospective studies in referenced literature.

C. Comparisons with Guidelines:

• CDC opioid prescribing guidelines for noncancer, nonpalliative pain management established in 2016 influenced prescribing trends.

D. This Trial's Contribution:

• Provides comprehensive, longitudinal data on opioid prescribing trends among emergency physicians within the Medicare Part D population, highlighting regional variations and shifts to alternative opioids.
• Confirms declines in traditional opioid use while identifying an increase in tramadol and acetaminophen-codeine prescriptions, aligning with national stewardship efforts.

Clinical Application

How Findings Change Current Practice:

• Supports the continued reduction of traditional opioid prescriptions in emergency settings.
• Highlights the need for cautious use and monitoring of alternative opioids like tramadol and acetaminophen-codeine.

Specific Patient Populations or Scenarios:

Particularly relevant for elderly patients who are more vulnerable to adverse effects of alternative opioids.

Implementation Considerations:

• Development of region-specific guidelines to address varied prescribing patterns.
• Enhanced training for emergency physicians on the risks associated with alternative opioids.

Integration with Existing Evidence:

Aligns with national opioid stewardship initiatives aiming to curb opioid misuse and overdose.

How To Use This Info In Practice

Practitioners should consider continuing to reduce traditional opioid prescriptions while carefully evaluating the use of alternative opioids, ensuring they are prescribed judiciously and with appropriate patient monitoring.

Notes for Clarity:

• Bolded Statistical Significance: Key statistical changes (e.g., declines in prescribing rates, costs) are highlighted in bold to emphasize their importance.
• Confidence Intervals: Not explicitly provided in the original study; however, significant trends are assumed based on large data volumes.
• Conflicts of Interest: The authors declare no conflicts of interest.
• Funding Sources: Not specified in the provided text.
• Areas of Uncertainty: The shift to alternative opioids raises questions about long-term impacts and potential new risks.
• Number Needed to Treat/Harm: Not applicable due to the descriptive nature of the study.
• Post-hoc Analyses: Not reported.
• Funding Sources: Not mentioned, assuming none disclosed.

This structured summary provides a comprehensive overview of the study, facilitating rapid understanding and application of the findings in clinical practice, research, and healthcare decision-making.