Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use

Treatment by high-opioid prescribing physicians in the emergency department (ED) is associated with higher rates of long-term opioid use among Medicare beneficiaries. However, it is unclear if this result is true in other high-risk populations such as Veterans. To estimate the effect of exposure to high-opioid prescribing physicians on long-term opioid use for opioid-naïve Veterans. Observational study using Veterans Health Administration (VA) encounter and prescription data. Veterans with an index ED visit at any VA facility in 2012 and without opioid prescriptions in the prior 6months in the VA system ("opioid naïve"). We assigned patients to emergency physicians and categorized physicians into within-hospital quartiles based on their opioid prescribing rates. Our primary outcome was long-term opioid use, defined as 6months of days supplied in the 12months subsequent to the ED visit. We compared rates of long-term opioid use among patients treated by high versus low quartile prescribers, adjusting for patient demographic, clinical characteristics, and ED diagnoses. We identified 57,738 and 86,393 opioid-naïve Veterans managed by 362 and 440 low and high quartile prescribers, respectively. Patient characteristics were similar across groups. ED opioid prescribing rates varied more than threefold between the low and high quartile prescribers within hospitals (6.4% vs. 20.8%, p < 0.001). The frequency of long-term opioid use was higher among Veterans treated by high versus low quartile prescribers, though above the threshold for statistical significance (1.39% vs. 1.26%; adjusted OR 1.11, 95% CI 0.997-1.24, p = 0.056). In subgroup analyses, there were significant associations for patients with back pain (adjusted OR 1.25, 95% CI 1.01-1.55, p = 0.04) and for those with a history of depression (adjusted OR 1.28, 95% CI 1.08-1.51, p = 0.004). ED physician opioid prescribing varied by over 300% within facility, with a statistically non-significant increased rate of long-term use among opioid-naïve Veterans exposed to the highest intensity prescribers.

<h3></h3> The negative effects of long-term prescription opioid use are well-documented, yet long-term use has increased dramatically in recent years. Clinical guidelines recommend low-severity injury patients not receive opioids early in the course of their care, but supporting evidence is limited. Previous studies have compared those receiving opioids early to those not receiving opioids early, a substantial portion of which never received opioids at all. The present study utilises a sizeable dataset from a large, national workers' compensation insurer to make the more relevant comparison between those receiving opioids early and those receiving opioids late. Claims data from 123,096 claimants with low-severity back and shoulder injuries from 1999 to 2010 were analysed. Long-term opioid use (&gt;3 months) was compared between those who received opioids early (≤1 month after injury) and late (&gt;1 month). Back-injured claimants with early opioid use had 33% lower (95% CI: 24%–41% lower) odds of long-term opioid use than claimants with late opioid use, after adjusting for key covariates. Shoulder-injured claimants with early opioid use had 29% higher (95% CI: 6%–58% higher) odds of long-term opioid use than those with late opioid use. Stratified analyses indicated that, for both back and shoulder, among claimants with unclear diagnoses within the first month of injury, early opioid use was related to higher risk for long-term opioid use. Among patients with low-severity diagnoses, later opioid use does not appear to decrease risk of long-term use. However, there may still be a benefit to delaying opioid prescription if a diagnosis cannot be ascertained.

Opioids are essential medicines for pain management; however, long-term use is associated with negative outcomes, including addiction. The aim of the study was to analyze the risk of long-term use after an initial opioid prescription and examine associated sociodemographic and health care-related risk factors. We identified a strictly defined, five-year opioid-naïve population of adults aged 18-64 years who received an initial opioid prescription between 2016 and 2020 in Swedish national registers. We modeled the association between individual characteristics and odds of long-term ( > 3 months) versus short-term ( ≤ 3 months) use, and odds of different durations of use ( > 3-6, >6-12, and >12 months) using logistic regression analyses. Of 754,982 opioid-naïve individuals with an initial opioid prescription, 8.1% use opioids long-term. Individuals treated for a recent external injury have lower odds of long-term opioid use (e.g., >12 vs ≤3 months: OR 0.55, 95% CI 0.52-0.59), whereas those who initiated treatment in primary care have higher odds (e.g., >12 vs ≤3 months: OR 3.02, 95% CI 2.90-3.14). Individuals with a history of substance use disorders and greater use of psycholeptic drugs have higher odds of long-term use. Sociodemographic factors, including older age, lower education level, and not cohabiting are also associated with longer durations of use. Of opioid-naïve individuals, 8.1% develop long-term prescription opioid use, with higher odds among individuals with psychiatric history and whose opioid treatment initiated in primary care. Careful evaluation of patient health and regular follow-up are essential to reduce the risk of long-term opioid use.

BACKGROUND: Long-term opioid therapy was prescribed with increasing frequency over the past decade. However, factors surrounding long-term use of opioids in older adults remains poorly understood, probably because older people are not at the center stage of the national opioid crisis. OBJECTIVES: To estimate the annual utilization and trends in long-term opioid use among older adults in the United States. STUDY DESIGN: Retrospective cohort study. SETTING: Data from Medicare-enrolled older adults. METHODS: This study utilized a nationally representative sample of Medicare administrative claims data from the years 2012 to 2016 containing records of health care services for more than 2.3 million Medicare beneficiaries each year. Medicare beneficiaries who were 65 years of age or older and who were enrolled in Medicare Parts A, B, and D, but not Part C, for at least 10 months in a year were included in the study. We measured annual utilization and trends in new long-term opioid use episodes over 4 years (2013–2016). We examined claims records for the demographic characteristics of the eligible individuals and for the presence of chronic non-cancer pain (CNCP), cancer, and other comorbidities. RESULTS: From 2013 to 2016, administrative claims of approximately 2.3 million elderly Medicare beneficiaries were analyzed in each year with a majority of them being women (~56%) and white (~82%) with a mean age of approximately 75 years. The proportion of all eligible beneficiaries with at least one new opioid prescription increased from 6.64% in 2013, peaked at 10.32% in 2015, and then decreased to 8.14% in 2016. The proportion of individuals with long-term opioid use among those with a new opioid prescription was 12.40% in 2013 and 10.20% in 2016. Among new long-term opioid users, the proportion of beneficiaries with a cancer diagnosis during the study years increased from 13.30% in 2013 to 15.67% in 2016, and the proportion with CNCP decreased from 30.25% in 2013 to 27.36% in 2016. Across all years, long-term opioid use was consistently high in the Southern states followed by the Midwest region. LIMITATIONS: This study used Medicare fee-for-service administrative claims data to capture prescription fill patterns, which do not allow for the capture of individuals enrolled in Medicare Advantage plans, cash prescriptions, or for the evaluation of appropriateness of prescribing, or the actual use of medication. This study only examined long-term use episodes among patients who were defined as opioid-naive. Finally, estimates captured for 2016 could only utilize data from 9 months of the year to capture 90-day long-term-use episodes. CONCLUSIONS: Using a national sample of elderly Medicare beneficiaries, we observed that from 2013 to 2016 the use of new prescription opioids increased from 2013 to 2014 and peaked in 2015. The use of new long-term prescription opioids peaked in 2014 and started to decrease from 2015 and 2016. Future research needs to evaluate the impact of the changes in new and long-term prescription opioid use on population health outcomes. KEY WORDS: Long-term, opioids, older adults, trends, Medicare, chronic non-cancer pain, cancer, cohort study

OP0087 NATIONAL VARIATION AND FACTORS ASSOCIATED WITH THE TRANSITION FROM FIRST USE TO LONG-TERM OPIOID USE FOR NON-CANCER PAIN

Burn Injury and Long-Term Opioid Use.

Background Physician prescribing behaviour has been described as a key driver of rising opioid prescriptions and long-term opioid use. However, the effect of prescribers requires interpretation within context. No studies have investigated the extent to which regions, practices, prescribers, vary in opioid prescribing by considering this hierarchy together, whilst accounting for case-mix. Objectives: (i)quantify and identify risk factors for the transition from new-users to long-term opioid users (ii) quantify variation of long-term use attributed to region, practice, prescriber, accounting for patient mix and chance variation. Methods We conducted a retrospective observational study between 2006-2017 using Clinical Practice Research Datalink. New users of opioids, ≥18 years, without cancer were identified. Long-term opioid use was defined as ≥ 3 opioid prescriptions within a 90-day period from index date, or ≥ 1 opioid prescription lasting at least 90-days in the first year. A multi-level random-effects logistic regression model was used to examine the association of patient characteristics with the odds of becoming a long-term opioid-user. To examine variation in opioid use among prescribers, GP-practices and region after adjusting for case-mix, we used a nested random-effect structure. A ‘high-risk’ region, prescriber or practice was defined as those where the entire adjusted 95% CI lay above population average. Results 1,968,742 new opioid users were included; 14.6% transitioned to long-term use. In the fully-adjusted model, factors associated with higher-odds of long-term use included high morphine-milligram equivalents (MME)/day at first prescription, older-age, deprivation, fibromyalgia, rheumatological conditions and prior surgery (Table 1). After adjustment for case-mix, the North-West, Yorkshire and South-West were found to be high-risk regions for long-term use. 103 practices (25.6%) and 540 prescribers (3.5%) were associated with a significantly higher risk of long-term use. The odds of becoming a long-term user for patients belonging to these prescribers reached up to &amp;gt; 3.5 times than the population average. Conclusion Prescribing factors, age, deprivation and conditions including fibromyalgia and rheumatological conditions were associated with higher odds of long-term opioid use. In the first UK study evaluating long-term opioid prescribing with patient-level characteristics adjustment, variation in regions, especially practices and prescribers were observed. Our findings support greater calls for action to reduce practice/prescriber variation by promoting safe practice in opioid-prescribing. Disclosures M. Jani: None. B. Birlie-Yimer: None. T. Sheppard: None. M. Lunt: None. W.G. Dixon: None.

Study Objective: We explore the emergency department (ED) contribution to prescription opioid use for opioid-naive patients by comparing the guideline concordance of ED prescriptions with those attributed to other settings and the risk of patients’ continuing long-term opioid use. Methods: We used analysis of administrative claims data (OptumLabs Data Warehouse 2009 to 2015) of opioid-naive privately insured and Medicare Advantage (aged and disabled) beneficiaries to compare characteristics of opioid prescriptions attributed to the ED with those attributed to other settings. Concordance with Centers for Disease Control and Prevention (CDC) guidelines and rate of progression to long-term opioid use are reported. Results: We identified 5.2 million opioid prescription fills that met inclusion criteria. Opioid prescriptions from the ED were more likely to adhere to CDC guidelines for dose, days’ supply, and formulation than those attributed to non-ED settings. Disabled Medicare beneficiaries were the most likely to progress to long-term use, with 13.4% of their fills resulting in long-term use compared with 6.2% of aged Medicare and 1.8% of commercial beneficiaries’ fills. Compared with patients in non-ED settings, commercial beneficiaries receiving opioid prescriptions in the ED were 46% less likely, aged Medicare patients 56% less likely, and disabled Medicare patients 58% less likely to progress to long-term opioid use. Conclusion: Compared with non-ED settings, opioid prescriptions provided to opioid-naive patients in the ED were more likely to align with CDC recommendations. They were shorter, written for lower daily doses, and less likely to be for long-acting formulations. Prescriptions from the ED are associated with a lower risk of progression to long-term use.

Opioid Prescribing for Opioid-Naive Patients in Emergency Departments and Other Settings: Characteristics of Prescriptions and Association With Long-Term Use

BackgroundThere is limited knowledge regarding prescription opioid use following the release of the 2016 CDC guidelines, which recommended prioritizing non-opioid therapies for chronic pain, prescribing the lowest effective opioid dose for the shortest duration, and closely monitoring to minimize risks. This study evaluated trends in new and long-term prescription opioid use among older Medicare beneficiaries from January 2013 to September 2020.MethodsThis cohort study utilized 5% national Medicare claims data from 2012 to 2020, including older Medicare beneficiaries (≥ 65 years) with Parts A, B, and D, but not Part C enrollment for at least 10 months in a year. Annual utilization of individual demographic and clinical characteristics, average morphine milligram equivalent (MME) of new prescriptions, percentage of high-dose new prescriptions (MME ≥ 50) users, percentage of short-acting formulation users, and the average days of supply of new prescriptions were reported. Trends in new and long-term prescription opioid use were measured and changes over time were assessed using joinpoint regression. Sensitivity analyses were performed to determine whether subgroups defined by race, region, and clinical characteristics followed the national trend over the study years or deviated from it.ResultsThe study included approximately 2.75 million Medicare beneficiaries annually, mostly women (56%) and white (81%), with a mean age of 75 years. The percentage of beneficiaries with at least one new prescription opioid use increased from 6.6% in 2013 to 10.1% in 2016 (annual percentage change (APC) = 14.2; 95% confidence interval (CI): 2.2–50.0) and significantly decreased afterward to 5.4% in 2020 (APC = −15.3; 95% CI: −32.2 to −9.1). The percentage of individuals with long-term opioid use among new prescription opioid users decreased steadily from 12.4% in 2013 to 8.6% in 2017 (APC = −11.6; 95% CI: −24.2 to −5.7). It increased afterward to 10.7% in 2020, although non-significant (APC = 7.4; 95% CI: −2.8 to 24.2). Sensitivity analyses demonstrate that subgroups defined by race, region, and clinical characteristics generally followed the national trend in new long-term opioid therapy episodes over the study years, with minimal difference in inflection points. The mean (SD) MME per new prescription declined from 31.5 (27.44) in 2013 to 26.82 (17.48) in 2020, and the percentage of high-dose prescription users fell from 15.3% in 2013 to 7.6% in 2020. Short-acting formulation users rose from 97.41% in 2013 to 99.41% in 2020, while the average (SD) days of supply per new prescription decreased from 21.91 (23.49) to 12.40 (15.27).ConclusionsA comprehensive assessment of trends in prescription opioid use before and after the release of the 2016 CDC guidelines suggested an overall decline in new and long-term prescription opioid use among older adults, as well as average dose and percentage of high-dose prescription opioid users.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40266-025-01237-x.

Persons with Alzheimer disease (AD) commonly present with chronic nonmalignant pain, but long-term use of opioids among this population has not been studied previously. Our aim was to investigate the prevalence of long-term (≥180 days) use of opioids for nonmalignant pain and associated factors among community-dwelling persons with AD and to compare the prevalence with a matched cohort without AD. The Medication use and Alzheimer's disease (MEDALZ) cohort was used for this study, comprising all community-dwelling persons diagnosed with AD in Finland during 2005 to 2011 and their matched comparison persons without AD. After exclusion of persons with active cancer treatment, 62,074 persons with and 62,074 persons without AD were included in this study. Data were collected from nationwide registers. Opioids were used by 13,111 persons with and by 16,659 without AD. Overall long-term opioid use was more common among persons without AD (8.7%) than among persons with AD (7.2%, P < 0.0001). However, among opioid users, prevalence of long-term opioid use was slightly higher among persons with AD than among those without AD (34.2% vs 32.3%, respectively, P = 0.0004). Long-term use of transdermal opioids was more than 2-fold among opioid users with AD (13.2%) compared with users without AD (5.5%). Factors associated with long-term opioid use included AD, age ≥80 years, female sex, rheumatoid arthritis, osteoporosis, low socioeconomic position, history of substance abuse, and long-term benzodiazepine use. Prevalence of long-term opioid use was somewhat similar among both groups. Among persons with AD, long-term opioid use was strongly associated with transdermal opioids.

To identify the extent to which opioid prescribing rates for patients with rheumatoid arthritis (RA) vary in the US and to determine the implications of baseline opioid prescribing rates on the probability of future long-term opioid use. We identified patients with RA from physicians who contributed ≥10 patients within the first 12 months of participation in the Corrona RA Registry. The baseline opioid prescribing rate was calculated by dividing the number of patients with RA reporting opioid use during the first 12 months by the number of patients with RA providing data that year. To estimate odds ratios (ORs) for long-term opioid use, we used generalized linear mixed models. During the follow-up period, long-term opioid use was reported by 7.0% (163 of 2,322) of patients of physicians with a very low rate of opioid prescribing (referent) compared to 6.8% (153 of 2,254) of patients of physicians with a low prescribing rate, 12.5% (294 of 2,352) of patients of physicians with a moderate prescribing rate, and 12.7% (307 of 2,409) of patients of physicians with a high prescribing rate. The OR for long-term opioid use after the baseline period was 1.16 (95% confidence interval [95% CI] 0.79-1.70) for patients of low-intensity prescribing physicians, 1.89 (95% CI 1.27-2.82) for patients of moderate-intensity prescribing physicians, and 2.01 (95% CI 1.43-2.83) for patients of high-intensity prescribing physicians, compared to very low-intensity prescribing physicians. Rates of opioid prescriptions vary widely. Our findings indicate that baseline opioid prescribing rates are a strong predictor of whether a patient will become a long-term opioid user in the future, after controlling for patient characteristics.

Hospital and long-term opioid use according to analgosedation with fentanyl vs. morphine: Findings from the ANALGESIC trial

BACKGROUND:Opioid prescription patterns, including long-term use, multiple prescribers, and high opioid doses, increase the risk for adverse outcomes; however, previous research in older adult populations has primarily described opioid dose patterns using average daily dose measures or using very high thresholds (i.e., > 100 morphine milligram equivalents [MME] per day).OBJECTIVE:To describe prescription patterns by peak dose among older adults who have newly initiated opioid use in 2014 and describe long-term opioid use and the use of multiple pharmacies and prescribers among those with peak opioid doses over 50 and over 90 MME per day.METHODS:This was a retrospective cohort study of Medicare Part D prescription claims data (5% sample) for beneficiaries aged 65 years and older who were prescribed ≥ 1 opioid prescription in 2014 and did not have an opioid prescription in the preceding 180 days. Within a 1-year period of follow-up, we used prescription claims to characterize individuals’ opioid exposure, measuring long-term opioid use (≥ 90 days of continuous opioid supply), unique opioid prescribers, and unique opioid-dispensing pharmacies. Peak MME was defined as the maximum daily MME received across all overlapping opioid prescriptions in the observation period.RESULTS:144,127 beneficiaries without an opioid prescription in the previous 6 months filled ≥ 1 opioid prescription in 2014. During the 1-year follow-up period, 6.5% of beneficiaries transitioned to long-term opioid use; 39.5% received opioid prescriptions from > 1 prescriber; 18.1% filled opioid prescriptions from > 1 pharmacy; and 21.8% had a peak MME of 50–89. Among the 28.1% of beneficiaries exposed to a peak MME ≥ 50, 8.6% developed long-term opioid use; 7.0% had 3 or more opioid dispensing pharmacies; and 28.0% had 3 or more opioid prescribers. Among the 6.2% of beneficiaries exposed to a peak MME ≥ 90, 18.5% developed long-term opioid use; 13.0% had 3 or more opioid dispensing pharmacies; and 39.6% had 3 or more opioid prescribers.CONCLUSIONS:High doses of opioids were prescribed for about one quarter (28%) of Medicare beneficiaries with new opioid use in 2014. Having multiple opioid prescribers or multiple opioid dispensing pharmacies was common, especially among those prescribed higher doses. These prescription patterns can be particularly helpful to identify older adults with increased opioid-related risk.

To the Editor: Barnett et al. (Feb. 16 issue)1 affirm a key hypothesis: seemingly random clinical exposure to opioids facilitates long-term use, at least among Medicare patients. Without careful inspection, readers may incorrectly interpret this finding to suggest that emergency physicians are key drivers of the opioid epidemic. Nationally, emergency department encounters account for only 5% of all opioids prescribed, even though they constitute more than 10% of all ambulatory visits.2 This study shows that the risk of long-term opioid use after treatment in an emergency department by a “high-intensity prescriber” is small at 1.51%, as compared with a 1.16% . . .