A Summary of “Evidence on Emerging data indicates NPs/PAs as a Group Prescribe More Opioids than Physicians”

This current pandemic lockdown has everyone spinning. What is there to do? I mean a nice 10 K run today followed by some relaxing weekend research reading and blogging. Can’t go out to hike a trail or even to pick up some donuts. With USMLE Step 3 behind me, why not write another blog? My last blog reported on a recent article Lozada et al (1) that stated: “Emerging data indicates NPs/PAs as a group prescribe more opioids than Physicians.” This is sort of part two of the Authentic Medicine Blog: (https://authenticmedicine.com/2020/05/a-summary-of-opioid-prescribing-by-primary-care-providers-a-cross-sectional-analysis-of-nurse-practitioner-physician-assistant-and-physician-prescribing-patterns/). They referenced three studies in support of this statement:

  1. Ellenbogen MI, Segal JB. Differences in opioid prescribing among generalist physicians, nurse practitioners, and physician assistants. Pain Med. 2019. 
  2. Muench U, Spetz J, Jura M, Guo C, Thomas C, Perloff J. Opioid-prescribing outcomes of Medicare beneficiaries managed by nurse practitioners and physicians. Med Care. 2019 
  3. Romman AN, Hsu CM, Chou LN, et al. Opioid prescribing to Medicare Part D enrollees, 2013-2017: shifting responsibility to pain management providers. Pain Med. 2020

They reported Ellenbogen et al. (2) that described “generalist NPs/PAs prescribe a disproportionately high quantity of opioids to Medicare Part D beneficiaries compared with MD (2).” In addition, they also reported on Romman et al (4), that stated “NPs/PAs significantly increased opioid prescribing from 2013 to 2017, a period when almost every medical specialty decreased opioid prescribing (4).” Lozada et al (1) then concluded that “future research to identify providers at highest risk of overprescribing requires a rigorous examination of providers’ years in practice, their educational backgrounds (NP vs DNP), associated diagnoses and pain scores, and patient volume and levels of acuity.” This last quote is supported in the referenced research (2-4). 

Ellenbogen et al. (2) conducted a study with the purpose to determine if there are differences in opioid prescribing among generalist physicians, nurse practitioners (NPs), and physician assistants (PAs) to Medicare Part D beneficiaries. This research was published in January 2020. They sampled 36,999 generalist physicians, NPs, and PAs from 2013 – 2016. The main outcomes were the total opioid claims and opioid claims as a proportion of all claims in patients treated by the prescribers. The number of adjusted total opioid claims was:

  1. Physicians 660 (95% CI = 660-661)
  2. NPs 755 (95% CI = 753-757)
  3. PAs 812 (95% CI = 811-814)

They concluded that “relatively high rates of opioid prescribing among NPs and PAs, especially at the upper margins. This suggests that well-designed interventions to improve the safety of NP and PA opioid prescribing, along with that of their physician colleagues, could be especially beneficial.” It’s also important to report sound statistical analysis utilized in the study utilizing confidence intervals (CI) and binomial regression. All CI’s were 95%. In statistics, binomial regression is a regression analysis technique in which the response has a binomial distribution: it is the number of successes in a series of independent Bernoulli trials, where each trial has probability of success is related to explanatory variables: the corresponding concept in ordinary regression is to relate the mean value of the unobserved response to explanatory variables. Journal Impact Factor of the Pain Medicine Journal is 2.76 and 5-year Impact Factor is 3.18. Authors are MD’s. 

Muench et al (3) in a 2019 study determined that primary care providers are at the center of the opioid epidemic. The purpose was to determine whether NPs have different opioid prescribing outcomes from physicians, by examining opioid-prescribing outcomes of Medicare beneficiaries receiving care from NPs and physicians in primary care. They examined Medicare data of beneficiaries residing in states in which NPs were able to prescribe without physician oversight. I wasn’t able to gain full access to the article, but it didn’t mention physicians in the subject’s section of the abstract. I’m not sure if the full article measured physician data, but outcomes listed in the abstract included only results for NPs. They measured as follows:

  1. whether beneficiaries received any opioid prescription. 
  2. for beneficiaries who received opioids, we measured acute (<90 d supply) and chronic (≥90 d supply) use at baseline (2009–2010) and follow-up (2012–2013). 
  3. potential misuse of opioid prescribing using 
    1. a daily morphine milligram equivalent dose of >100 mg, overlapping prescriptions of opioids >7 days, and 
    1. overlapping prescriptions of opioids with benzodiazepines >7 days

While the abstract didn’t include physician data, they reported the following results, beneficiaries managed by NPs 

  1. were less likely to receive an opioid [odds ratio (OR), 0.87; P<0.001], 
  2. were less likely to be acute users at baseline (OR, 0.84; P<0.001), and 
  3. were more likely to receive a high daily opioid dose of morphine milligram equivalent >100 mg compared with physician-managed beneficiaries (OR, 1.11; P=0.048)

If I had access to the full article, I could look more at the statistics. But suffice to say, an odds ratio is a measure of association between the presence or absence of two properties.  For example, it could provide a measure of association between customers who are either older or younger than 25 and either have or have not claimed on their car insurance, in order to determine whether age is associated with the propensity to claim. The value of the odds ratio tells you how much more likely someone under 25 might be to make a claim, for example, and the associated confidence interval indicates the degree of uncertainty associated with that ratio.

            They concluded the following:

  1. Findings suggest educational programs and clinical guidelines may require approaches tailored to different providers. 
  2. Future research should examine the contributing factors of these patterns to ensure high-quality pain management and guide policy makers on NP-controlled substance-prescribing regulations.

The original article reviewed, Lozada et al. (1), used data from Muench et al (3) in support of their operative definition of overprescribing and their conclusion that 8.0% of NPs and 9.8% of PAs met at least one definition of opioid overprescribing compared with 3.8% of physicians. In addition, the afore mentioned conclusions of Muench et al (3) are consistent with Lozada et al. (1): “future research to identify providers at highest risk of overprescribing requires a rigorous examination providers’ years in practice, their educational backgrounds (NP vs DNP), associated diagnoses and pain scores, and patient volume and levels of acuity.” The journal Medical Care, has an Impact Factor of 3.795. The lead researcher was an RN PhD and the other co-researchers are PhDs. 

Romman et al (4), is similar to the other articles reviewed and the original article. Their purpose is to examine opioid prescribing frequency and trends to Medicare Part D enrollees from 2013 to 2017 by medical specialty and provider type (physicians, dentists, nonphysician providers). Study design is a retrospective, cross-sectional, specialty- and provider-level analysis of Medicare Part D prescriber data for opioid claims from 2013 to 2017. The following are the results of this study:

  1. Every other medical specialty decreased opioid claims over this period, with emergency medicine (-19.9%) and orthopedic surgery (-16.0%) dropping opioid claims more than any specialty. 
  2. Physicians overall decreased opioid claims per provider by -5.2%. 
  3. opioid claims among both dentists (+5.6%) and nonphysician providers (+10.2%) increased during this period.

I also didn’t have full access to this article so I can’t comment on the statistics and analysis methods. The majority of authors are MDs/DOs. This is a 2020 article.  Journal Impact Factor of the Pain Medicine Journal is 2.76 and 5-year Impact Factor is 3.18. They concluded:

From 2013 to 2017, pain management and PMR increased opioid claims to Medicare Part D enrollees, whereas physicians in every other specialty decreased opioid prescribing. Dentists and nonphysician providers also increased opioid prescribing. Overall, opioid claims to Medicare Part D enrollees decreased and continue to drop at faster rates.

            So overall, the evidence used in Lozada et al (1) seems pretty sound. I’m tired so I”ll leave it there. 

References:

  1. Lozada, M.J., Raji, M.A., Goodwin, J.S. et al. Opioid Prescribing by Primary Care Providers: a Cross-Sectional Analysis of Nurse Practitioner, Physician Assistant, and Physician Prescribing Patterns. J GEN INTERN MED (2020). https://doi.org/10.1007/s11606-020-05823-0
  2. Ellenbogen MI, Segal JB. Differences in opioid prescribing among generalist physicians, nurse practitioners, and physician assistants. Pain Med. 2019. https://doi.org/10.1093/pm/pnz005
  3. Muench U, Spetz J, Jura M, Guo C, Thomas C, Perloff J. Opioid-prescribing outcomes of Medicare beneficiaries managed by nurse practitioners and physicians. Med Care. 2019 
  4. Romman AN, Hsu CM, Chou LN, et al. Opioid prescribing to Medicare Part D enrollees, 2013-2017: shifting responsibility to pain management providers. Pain Med. 2020 
  5. https://select-statistics.co.uk/calculators/confidence-interval-calculator-odds-ratio/

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Robert Duprey MD

Robert is a 2nd career physician (MD); a combat Veteran with the US Army; a former psychiatric nurse practitioner; an independent researcher; a medical writer; and now having passed USMLE Steps 1, 2CK, 2CS, and 3, is a residency applicant. 

  2 comments for “A Summary of “Evidence on Emerging data indicates NPs/PAs as a Group Prescribe More Opioids than Physicians”

  1. Mamadoc
    May 8, 2020 at 9:20 am

    This has been known to me true in my state for some time.

  2. Steve O'
    May 6, 2020 at 9:25 pm

    How dare they publish material simply relying on truth without an eye to social justice!? Trofim Lysenko provied in biology that individuals can change their own genetic structure based on the tasks and genes that they do more frequently. I know, you are saying that Lysenko merely copied Lamarcke’s theories of environmentally acquired inheritance. Didn’t Mao Zedong believe in the social justice-genetics model of truthing the future in his Great Leap Forward in 1957?
    Actually, it goes to show you that people can be sold sh*t in a Betty Crocker tin, and be too cowardly to believe the truth, rather than going along with the herd. Lamarcke didn’t kill that many people with his falsehood of individual modification of one’s own genes. Lysenko had the the endorsement of Josef Stalin, whom nobody questioned – twice. Mao’s brilliant adherence to social hoodoo and mental witchcraft over truth caused over 50 MILLION Chinese to starve to death for the sake of neglecting scientific truth over social fashion. This research will be neatly shelved under the file of “Doctors cause opiate deaths,” and be used to accelerate the very engine of destruction of American Medicine.

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