Opioid prescribing is more likely toward the end of the clinic day and as appointments run farther behind. A pain specialist reviews study findings.
Prescribing in a Perfect World. In a perfect world, physicians would provide the same care for a patient seen during the last appointments of the day as during the morning appointments.
However, this does not appear to be always the case.
Downsides of Late-day Appointments. A study published earlier this year found that for patients seen in primary care clinics, the later in the day their appointment times, the less likely they were to be referred for breast and colorectal cancer screening tests and to complete them.1 A new study published in JAMA Network Open reports a similar phenomenon when it comes to the prescription of opioids.2
New Painful Conditions, Established Patients. Using data from EHRs in primary care offices, the study examined appointment times for patients with a new painful condition who had not received an opioid prescription within the previous year. Authors examined records of 642 262 patients (61% women) seen by 5,603 primary care physicians.
33% Increase in Opioid Rx Late in Day. For patients who had the 19th - 21st appointments in the day, there was a 33% relative increase in likelihood of an opioid prescription vs those seen during visits 1 - 3. Similarly, the later the appointments ran behind schedule, the more likely opioids were to be prescribed.
Consistent Prescribing Rate, Lowere Overall Opioid Rx. Opiod Prescribing If the opioid prescribing rate had remained constant over the course of the day, the authors calculated that there would have been 4459 fewer opioid prescriptions written over the course of a year.
Non-opioid Rx Not Affected by Time of Day. The study also looked at the impact of appointment time on prescription of nonsteroidal anti-inflammatory drugs (NSAIDs) and referral to physical therapy for pain, and found no such effect. Not examined, however, was whether there was any impact on physician recommendations to purchase over-the-counter NSAIDs.
Opioid Epidemic is to Blame. Many patients still believe that opioids are always the optimal analgesics and that other treatments recommended for pain reflect substandard care. More recently many patients also feel that physician hesitancy to prescribe opioids is related to the “opioid epidemic” and not to concerns about quality of care. By extension the assumption is that they are being forced to suffer because others have abused the drugs.
Saying "Yes" to Opioids is Understandable. Given the constraints of clinical practice, (eg, time, financial pressure, productivity expectations) it is understandable that while patient requests for opioids may stay constant during a clinic day, the clinician’s ability to counsel against them declines and the likelihood of acquiescing to the request increases. A clinician behind schedule toward day’s end may opt to avoid counseling on the benefits of other options even when they feel opioids aren’t indicated.
End of Day Prescribing Down for Flu Vaccine. Similar results were found in a study looking at time of day and antibiotic prescription -- the later in the day the appointment time, the more likely patients were to be prescribed antibiotics for acute respiratory infections with little or no valid indication found.3 The study authors cite another study that found influenza vaccination rates decreased from 44% to 32% throughout the day-a 27% relative decrease.
Which Patient Types Receive Opioids? The study did not determine that there were any patient characteristics that were likely to result in an increased likelihood of an opioid prescription. However, most of the patients with pain complained of back, joint, and/or other musculoskeletal pain so, if possible, physicians might see if these patients could be scheduled earlier in the day.
Physician, Know Thyself. Whether self-employed or employed by others, most primary care physicians face demands to see as many patients as possible in the course of the day and that is not likely to change. The study findings suggest that these physicians need to be aware, then, that the pressures of time may lead them to make some decisions that could result in less than optimal care for their patients.
1. Hsiang EY, Mehta SJ, Small DS, et al. Association of primary care clinic appointment time with clinician ordering and patient completion of breast and colorectal cancer screening. JAMA Network Open. 2019.2(5):e19403.
2. Neprash HT, Barnett ML. Association of primary care clinic appointment time with opioid prescribing. JAMA Network Open. 2019.2:e1910373.
3. Linder JA, Doctor JN, Friedberg MW, et al. Time of day and the decision to prescribe antibiotics. JAMA Intern Med. 2014;174:2029-2031.
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