Appointment Timing and Opioid Prescribing

Recent evidence suggests that physicians’ prescribing behavior may play a central role in the national opioid epidemic. Because avoiding opioid prescribing for pain can require significant counseling on non-pharmacologic options, physicians have incentives to simply prescribe opioids for a “quick win.” We hypothesized that this incentive may become more powerful as physicians’ clinical sessions progress due to cognitive fatigue. In this paper, we provide the first national, EHR-based evidence that primary care physicians’ decision-making regarding opioid initiation for patients with chronic pain varies over the course of the workday and workweek. Using data from athenahealth, we performed a retrospective analysis of patients with an established painful condition, who saw their primary care physician from 2013-2014 without a previous opioid prescription in the past year. We assessed the relationship between appointment schedule characteristics (time-of-day and day-of-week) and opioid prescribing within the same physician, with adjustment for patient characteristics. We observed a monotonic increase in rates of opioid prescribing as appointment start hour progressed during the morning. Controlling for appointment start hour, physicians were more likely to prescribe opioids during an appointment immediately preceding a scheduled break, compared to immediately following. Physicians were also significantly more likely to prescribe an opioid as the work week progressed. We found no similar patterns for NSAID or antidepressant prescribing, nor referral to physical therapy, suggesting that cognitive fatigue plays a role in physician decision-making regarding potentially inappropriate prescribing.