Physicians are more likely to prescribe opioids later in the workday or when schedules run behind schedule, according to study.
While fatigue may play a role in increased opioid prescriptions, the study published in JAMA Network Open on Friday did not find similar increases in non-opioid pain treatment prescriptions or referrals to physical therapy.
The study looked at more than 678,000 appointments with more than 5,600 primary care physicians during 2017 and found the likelihood of an opioid being prescribed rose by 33% as the workday progressed.
Opioid prescribing rates have steadily declined since 2012, but there were still more than 58 prescriptions written per 100 Americans in 2017, according to the Centers for Disease Control and Prevention.
Researchers estimated that if clinicians had maintained their opioid prescription rate from their first three visits throughout the day, there would have been 4,400 fewer prescriptions in 2017 within the group studied.
The findings could help researchers understand how appointment timing and fatigue could play a role in the opioid epidemic.
"This study does provide some empirical evidence that physicians possibly take the easier way out when dealing with patients complaining of pain when they are short on time or when they maybe have limited cognitive bandwidth at the end of the day," said Dr. Michael Ellenbogen, assistant professor of medicine at Johns Hopkins University School of Medicine.
It's not the first time researchers have found a link between prescription rates and the time of day. A 2014 JAMA Internal Medicine study found that rates of inappropriate antibiotic prescribing for acute respiratory infections increased over the course of the workday.
Ellenbogen said the study was helpful in raising awareness of the problem but stopped short of recommending hospitals make systemic changes to their opioid stewardship programs based on the study results.
"The more aware we are of these limitations the better (prepared) we are to deal with them, and I think it's an avenue for new research to see in what other areas is our clinical decision-making impaired when we are rushed for time," Ellenbogen said. "I don't think as a result of this study physicians are suddenly going to be granted more time to see patients."
Educating physicians about treatment alternatives and making them aware o their prescribing practices is important, Ellenbogen said.
Neither the CDC nor any of the country's major professional medical organizations include recommendations on how healthcare providers should address clinician time pressures to reduce overprescriptions.
Michael Ganio, director of pharmacy practice and quality for the American Society of Health-System Pharmacists, said the research shows there's a need for consistent opioid stewardship guidelines. But he didn't say whether ASHP had addressed or planned to investigate the implications of the study's findings.
Lindsey Philpot, an epidemiologist at the Mayo Clinic, said it was validating to see the effects of cognitive fatigue was being examined among other populations.
Philpot co-authored a 2018 study published in the Journal of General Internal Medicine that found an association between workplace fatigue and physicians deviating from professional clinical guidelines and increased likelihood of prescribing opioids later in the day.
But Philpot argued for a more systemic approach by healthcare providers in solving the problem rather than leaving it to the individual physician.
In July 2018, Mayo began including alerts within its electronic medical record system to help physicians make wiser decisions when it came to opioid prescribing that provide recommendations on how much and how many days they should prescribe such medications for an individual patient.
She said tailoring medical education on cognitive fatigue to improve opioid prescribing may not be enough since it has been shown to affect their ability to make other types of clinical decisions.
"Cognitive fatigue is not just specific to opioid prescribing so we really think a more system-based approach will probably be in our best interest in the long term," she said.
