The opioid epidemic continues to grow nationwide.
A new study has found that, in a startling number of visits to a physician between 2006 and 2015 when an opioid was prescribed — nearly 30 percent — there was no recorded indication for pain.
The apparent lack of a paper trail related to opioid prescriptions is just one more facet of a public health quagmire.
The study, published this month in the Annals of Internal Medicine, highlights a potential administrative problem among physicians who prescribe opioids, and a need for better documentation practices.
“The key interpretation to take away there is it does not necessarily mean that 30 percent of opioid prescriptions were inappropriate or not given for the right medical reasons, we can’t conclude that,” said Dr. Tisamarie Sherry, an associate physician policy researcher at the RAND Corporation and an instructor at Harvard Medical School. “But, what we do know is that in 30 percent of the cases, we just don’t know why the opioid was prescribed, and we think that’s a problem.”
In the study, opioids were found to be prescribed in 31,943 visits, of which only 5 percent documented a cancer-related pain diagnosis.
In 66 percent of cases, there was a diagnosis for noncancer pain conditions.
Researchers also found that during visits in which a patient was continuing an opioid prescription, as opposed to being prescribed one for the first time, the lack of a pain diagnosis was even more common.
“When the doctor is renewing an opioid prescription, documentation practices appear to be even more lax,” said Sherry.
The study raises the question of the appropriateness of how frequently opioids are prescribed to patients, and if the diagnosis is serious enough to call for opioid medications, shouldn’t that be recorded appropriately?
The story may not be that simple. Other experts contacted by Healthline indicated that the methodology of the study could have exacerbated the discrepancy in opioid prescribing with the lack of pain diagnosis.
The study used data from the National Ambulatory Medical Care Survey, which uses ICD codes to reference different diagnoses. These codes are culled from billing data and not directly from a physician’s chart for a patient — meaning that it’s possible that a pain diagnosis could have been recorded but never made it into the hospital’s billing information.
“ICD codes, like many medical documentation requirements, are not designed for promoting good clinical care. Their primary role is to support billing, payments, and other administrative needs. This means they aren’t a good way to measure quality of clinical care,” said Dr. Erin E. Krebs, Women’s Health Medical director, Minneapolis VA Health Care System.
Dr. Andrew Kolodny, co-director of Opioid Policy Research at the Heller School for Social Policy and Management at Brandeis University, similarly told Healthline “It’s just very difficult to know for certain what they found because they didn’t look at a chart, they looked at a medical claim.”
Still, Kolodny found the study to be compelling in other ways. Referring to the extraordinarily low number of opioid prescriptions for cancer-related pain, he said: “I think it sheds light on opioid prescribing patterns in the United States, that in other words, only a small percentage of patients receiving opioids have a condition for which the opioids might be appropriate, like cancer.”
Although opioids are prescribed widely for a variety of conditions, recent research has called their effectiveness into questions for chronic pain conditions, particularly in light of the increased dangers posed by the drugs on patients.
Deaths related to opioids in the United States have surged in recent years, with nearly 50,000 dying from them in 2017, according to the National Institute on Drug Abuse. Between 2002 and 2017, there has been a more than fourfold increase in the total number of deaths from opioid overdoses.
Recent studies have suggested that the overprescribing of opioids has played a significant contributing role in the ongoing crisis. In the United States in 2015, 240 million opioid prescriptions were dispensed — nearly one for every adult.
According to Sherry, the results of their study offer a new key piece of evidence in how overprescribing can be evaluated and, hopefully, fixed.
“The relevance of these findings is that if documentation practices are lax and we don’t even have a good handle of why opioids are being prescribed, we can’t even begin to take effective steps to identify overprescribing, let alone decrease it,” Sherry said. “That basic information about why people are giving out opioids is critical.”
The study concludes that there is a need for more robust, clinical documentation from physicians in cases where opioids are being prescribed. That, of course, may result in an increased administrative burden for doctors who may already feel under pressure from their everyday duties.
But to keep patients safe, that could be a small price to pay.
“The most meaningful ways to change prescribing practices are really going to involve doctors,” said Kolodny. “A proper medical record should indicate a rationale for the dangerous treatment, and the reason why the prescriber believes that the risks outweigh the benefits for a particular patient, so that documentation is critical.”