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Opioid intervention

‘Second opinion’ by another prescribing doctor within 30 days of an opioid prescription reduces long-term opioid use by 31%, concludes a new study led at Cambridge Judge Business School.

High angle view of a prescription bottled filled with pills surrounded by more of the same tablets, with copy space,

A “second opinion” by another prescribing doctor within 30 days of an initial opioid prescription reduced long-term opioid use after 12 months by 31%, says a new study led at Cambridge Judge Business School based on a nationwide US medical claims database of 3.5 million patients.

The study, “Curbing the opioid epidemic at its root”, forthcoming in the journal Management Science breaks new ground by focusing on early intervention rather than later management of chronic opioid use.

There were nearly 247,000 deaths in the US due to overdoses involving prescription opioids in 1999-2019, with such deaths quadrupling over that period, according to the US Centers for Disease Control and Prevention (CDC). The 12-month period to May 2020 had the highest number of drug overdose deaths ever recorded in a 12-month period, suggesting an acceleration during the coronavirus pandemic.

The new study asks a basic question in battling the opioid scourge: who should revisit and potentially revise an opioid-based treatment plan, the initial prescriber or a separate doctor? The research concludes that a separate clinician (known as “provider discordance”) reduces long-term opioid use, due partly to an immediate reduction in opioids prescribed after the follow-up appointment – and this holds true whether the patient’s initial prescriber was their regular doctor or another clinician.

“Our analysis indicates that systematic, operational changes in the early stages of managing new opioid patients may offer a promising, and hitherto overlooked, opportunity to curb the opioid epidemic,” says the study.

Many opioid intervention strategies centre on clinical management of ongoing dependence by chronic users, as they are the prime victims of overdose, but the new study focuses instead on the benefits of operational intervention during the early phases of opioid use.

Stefan Scholtes.
Professor Stefan Scholtes

“We conclude that a second opinion for patients recently prescribed opioids can significantly disrupt the too-often-trod path to long-term opioid use,” says study co-author Stefan Scholtes, Dennis Gillings Professor of Health Management at Cambridge Judge Business School and Director of the School’s Centre for Health Leadership & Enterprise. “This identifies an important avenue in helping to fight this enormous and sad problem that is afflicting communities in the US and beyond.”

The study focuses on new opioid patients in the primary care setting, as primary care clinicians are the largest group of opioid prescribers and often serve as the first encounter for patients with non-cancer pain. Although some patients do not return to this primary care setting because their pain has subsided, other patients return for further diagnosis – so such follow-up appointments offer the opportunity to revisit and possibly revise prescriptions.

The study is based on a dataset that includes insurance claim information of 3.5 million beneficiaries in the US who were insured by a commercial or government (Medicare or Medicaid) plan and had at least 18 months of continuous medical and pharmaceutical claims eligibility between September 2012 and December 2018. After excluding some patients such as those diagnosed with cancer and those under age 18, the study identified 11,340 new opioid patients who had follow-up appointments within 30 days – of whom 3,211 (28.3%) were seen by a different doctor.

The conclusion that the likelihood of long-term opioid use is 31% lower for patients who followed up with an alternate primary care clinician is based on a model that controls for various factors including the strength and days supplied of the initial opioid prescription. The result is confirmed by statistical models that account for patient selection effects.

“High-quality medical decision-making is at the heart of good medicine, yet it cannot be taken for granted,” the researchers conclude. “This study demonstrates that systematic operational changes in the primary care setting following opioid initiation may be a promising target to reduce the influx of patients afflicted by the opioid epidemic.”

The study – entitled “Curbing the opioid epidemic at its root: the effect of provider discordance after opioid initiation” – is co-authored by Katherine Bobroske, a PhD candidate at Cambridge Judge Business School, who is affiliated with the school’s Centre for Health Leadership & Enterprise and with Evolent Health in Arlington, Virginia, US;  Michael Freeman of INSEAD in Singapore; Lawrence Huan (MD) of the Centre for Health Leadership & Enterprise; Anita Cattrell of Evolent Health; and Professor Stefan Scholtes of Cambridge Judge.