Opioid Prescribing Varies Even Within Single Institution

Pauline Anderson

September 30, 2016

SAN ANTONIO — A new study shows marked differences in opioid prescribing trends, even within the same institution.

The study establishes "benchmarks" for opioid prescribing and sheds light on trends, which might help address the worrisome rise in opioid use, says Alan F. Kaul, PharmD, Department of Pharmacy, Brigham and Women's Hospital (BWH), Boston, Massachusetts.

"Everyone is concerned about the opioid epidemic and whether there is overprescribing of opioids," said Dr Kaul. "We really have to look into what's driving the prescribing within the organization."

Dr Kaul's study was presented here at the American Academy of Pain Management Academy (AAPM) 2016 Annual Meeting. The AAPM recently changed its name to the Academy of Integrative Pain Management.

The study compared oral opioid prescriptions at BWH to that at the Brigham and Women's/Mass General Health Care Center (FXB).

BWH is a 757-bed medical and surgical facility with 45,352 admissions, 18,626 inpatient surgeries, 13,325 outpatient surgeries, and 62,098 emergency department visits annually. FXB provides ambulatory care for elective day surgery, urgent care, primary care, and more than 20 specialty services, including pain management.

Researchers retrospectively reviewed prescriptions filled at the two pharmacies from 2013 to 2015. They evaluated 28,477 oral opioid prescriptions, of which 21,346 were filled at BWH and 7131 at FXB.

They found that the use of hydrocodone rose significantly at the main hospital between 2013 and 2015 (160 to 222 morphine equivalent doses [MEDs]; P < .001 for the trend association with year).

This, said Dr Kaul, was despite a drop nationally in prescriptions for hydrocodone combination products since a change in scheduling. In 2014, the US Drug Enforcement Agency reclassified these products from a more permissive Schedule III to a more restrictive Schedule II category of the Controlled Substances Act.

Noted Disparities

The study also uncovered "noted disparities" between the day-surgery and the main facility.

For example, although prescriptions for MEDs of hydrocodone increased at BWH, there was no such trend at that facility for morphine and oxycodone. Meanwhile, at FXB, there was an upward trend of MED prescriptions for hydromorphone (155 to 191; P < .001) and oxycodone (1603 to 1738; P < .001), but not for hydrocodone, methadone, or morphine.

Overdose deaths involving prescription opioids have quadrupled in the United States since 1999, Dr Kaul pointed out. From 2000 to 2014, 150,000 of the almost half a million drug overdoses were related to prescription opioids, he said.

"With all the issues with opioid prescribing and potential abuse, you have to understand what your own organization is doing," said Dr Kaul. "You should benchmark practices and then try to educate prescribers who may be outliers."

The next step, said Dr Kaul, is for his research group to "look for more granularity." This will involve investigating opioid prescription trends by type of service provider, he said.

Commenting for Medscape Medical News, Robert Twillman, PhD, executive director, Academy of Integrative Pain Management, said that the patterns the study exposed "are a bit surprising," although in some ways the findings may make some sense.

"My own clinical experience suggests that prescribers can fall into idiosyncratic prescribing patterns, and it easily could be that the prescribers at one institution just have a different set of patterns than those at another institution."

Although he said it's unclear to him "whether this is a good thing or a bad thing or perhaps meaningless," the next step might be to investigate clinical outcomes related to differences in prescribing patterns.

"That would tell us if these differences are clinically meaningful," said Dr Twillman. "I'd encourage the authors to attempt some kind of follow-up study of this nature."

The authors have disclosed no relevant financial relationships.

American Academy of Pain Management (AAPM) 2016 Annual Meeting. Poster 22. Presented September 23, 2016.

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