How appointment time may influence opioid prescribing

Among the factors contributing to the overuse of opioid painkillers may be one as simple as a patient’s appointment time with their primary care doctor.

            That’s the conclusion of a new study in JAMA that looks at the relationship between opioid prescribing, the timing of the appointment and whether the doctor is running behind schedule.

The authors examined EHR data for about 678,000 pain treatment appointments with 5,600 primary care physicians during 2017. They found that 5.3 percent of patients seen in the doctor’s 19^th to 21^st appointment of the day were prescribed opioids, compared with 4 percent of those seen during the first through third appointments, a 33 percent difference.

Similarly, opioid prescribing increased as appointments began later, from 4.4 percent from zero to nine minutes late to 5.2 percent when appointments started an hour or more late, an 18 percent jump. The study did not reveal any differences in NSAID prescribing or referrals to physical therapy-the other leading pain management treatments-by appointment time. 

The authors hypothesize that by prescribing opioids, doctors avoid time-consuming discussions with patients about the advantages of nonopioid alternatives to pain management. In so doing, they lessen the time crunch that often occurs toward the end of the day, or get back on schedule if they are running behind.

The study’s findings have implications both for clinical decision-making and quality measurement, the authors say. In terms of decision-making, they note that the effect of long days or late appointments could influence other time-consuming clinical tasks, such as advance care planning, but these effects could be minimized by better standardization of sensitive treatment decisions.

In addition, they say, some quality measurements may have to be modified to account for the effects of appointment timing. Full-time clinicians, for example, may have higher rates of opioid prescribing because of the effort involved in long workdays. This could be addressed by helping doctors develop schedule modifications to reduce the number of taxing or time-consuming appointments at the end of the day.

The study, “Association of Primary Clinic Appointment Time With Opioid Prescribing” appears in the August 2019 issue of JAMA.