Who Prescribes More Opioids for Pain Relief? Physicians or Physician Extenders?

Photo of Dr. Michael Issac Ellenbogen, M.D.

Michael Ellenbogen, MD
Assistant Professor of Internal Medicine
Johns Hopkins School of Medicine 

What is the background for this study? What are the main findings?

Nurse practitioners (NPs) and physician assistants (PAs) are becoming an increasingly important and larger part of the healthcare workforce, especially in general internal medicine. To our knowledge, differences in opioid prescribing among generalist physicians, NPs, and PAs have not been evaluated. We aimed to learn if there are differences in opioid prescribing among generalist physicians, NPs, and PAs to Medicare beneficiaries.     

We performed a serial cross-sectional analysis of prescription claims from 2013 to 2016 using publicly available data from the Centers for Medicare and Medicaid Services. All generalist physicians, NPs, and PAs who provided more than ten total prescription claims between 2013 and 2016 were included. These prescribers were subsetted as practicing in a primary care, urgent care, or hospital-based setting.

We found that the overall volume and proportion of opioid prescribing is heavily right-skewed. The mean opioid prescription proportions (as a proportion of all prescription claims) for physicians in primary care, urgent care/walk-in clinics, and hospital medicine were 4.69, 6.72, and 6.66 relative to 7.10, 11.97, and 11.01 for PAs.  The adjusted total opioid claims across these four years for physicians was 660 (95% confidence interval: 660-661), for NPs was 755 

(95% CI: 753-757), and for PAs was 812 (95% CI: 811-814). 

What should readers take away from your report?

We find that generalist NPs and PAs may be prescribing a disproportionately high quantity of opioids to Medicare patients relative to generalist physicians. There are a number of potential explanations for this. 

One interesting point is that several state attorney generals have reported that Purdue Pharmaceuticals actively targeted nurse practitioners and physician assistants. It is important to note, however, that our study cannot show a causal link between Purdue’s marketing behavior and the increased rate of prescribing of these groups within the sphere of general internal medicine. There are likely of a number of different causes for the trend we observed. 

What recommendations do you have for future research as a result of this study?

This analysis suggests that resources specifically targeted to NPs and PAs could be especially effective at reducing opioid prescribing. Further research should evaluate whether high volume opioid prescribing NPs and PAs tend to be associated with specific organizations with high volume opioid prescribing physicians and whether there is an association between high volume opioid prescribing and other low-value or high-risk healthcare practices.   I

No disclosures to report.

Citation: Differences in Opioid Prescribing Among Generalist Physicians, Nurse Practitioners, and Physician Assistants

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