Blog | Tuesday, July 16, 2013

QD: News Every Day--Impressions of drug-seeking behavior drive ER providers' opioid prescribing

There was only fair agreement of drug abuse risk among emergency clinicians' impressions of patients and the monitoring program guidelines that are meant to help them, a study found.

A two-site, prospective observational study examined 38 emergency physicians and nurse practitioners assessed a convenience sample of 544 patients aged 18 to 64 years who presented to two academic medical centers with chief complaint of back pain, dental pain or headache from June 2011 to January 2013. Drug-seeking behavior was defined as when a patient had four or more opioid prescriptions from four or more providers in the 12 months before emergency department evaluation.

Emergency providers' impression of "drug seeking" behavior was documented, according to a deliberately vague definition, the authors noted, since drug seeking behavior is a subjective impression.

Emergency providers were then asked to review the patient's data in the Massachusetts Prescription Drug Monitoring Program records, and were again asked their impression of whether the patient was drug seeking and their current plan to prescribe opioids.

Results appeared online in the Annals of Emergency Medicine.

There was fair agreement between emergency providers' impressions of drug-seeking behavior and the data in the prescription drug monitoring program. Sensitivity was 63.2% (95% confidence interval [CI], 54.8% to 71.7%), specificity was 72.7% (95% CI, 68.4% to 77.0%), and positive predictive value was 41.2% (95% CI, 34.4% to 48.2%) for identifying drug-seeking behavior. After reviewing prescription drug monitoring program data, emergency providers changed plans to prescribe opioids at discharge in 9.5% of cases (95% CI, 7.3% to 12.2%), with 6.5% of patients (n=35) receiving opioids not previously planned and 3% (n=16) no longer receiving opioids.

Predictors for drug-seeking behavior by prescription drug monitoring program criteria were patient requests opioid medications by name (odds ratio [OR] 1.91; 95% CI, 1.13 to 3.23), multiple visits for same complaint (OR 2.5; 95% CI, 1.49 to 4.18), suspicious history (OR 1.88; 95% CI, 1.1 to 3.19), symptoms out of proportion to examination (OR 1.83; 95% CI, 1.1 to 3.03), and hospital site (OR 3.1; 95% CI, 1.76 to 5.44).

Researchers noted that several of the clinical factors that were significantly associated with providers' impressions of drug-seeking behavior were shared with actual drug-seeking behavior by prescription drug monitoring program definition, but the magnitudes of the odds ratios differed. While physicians emphasized on a "suspicious history" (OR 12.2) and "symptoms out of proportion to the examination" (OR 6.2), in the drug monitoring program, the odds ratios were 1.9 and 1.8, respectively.

Researchers wrote, "These findings ... indicate that physicians might place too much weight on gestalt or stereotyping and need to rely on more objective criteria, such as a patient requesting an opioid by name."