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Many E.R. Doctors Underestimate How Many Opioids They Prescribe

New research finds presenting them with actual numbers can change their behavior.

Self-deception can often lead to negative consequences, as anyone who tells themselves they eat healthy, only to be shocked when they step on a scale, can attest. But the problem is more serious when the un-self-aware person is a physician who believes they are careful in prescribing opioids.

A new study of emergency room doctors finds nearly two-thirds prescribe more of the highly addictive pain relievers than they realize.

"Most believe they are doing the right thing," said Sean Michael of the University of Colorado School of Medicine, the study's lead author. "We need to directly address this thinking to be sure they are not part of the problem."

The study, published in the journal Academic Emergency Medicine, featured 109 emergency-medicine providers at four hospital emergency departments—two in urban locations, one in a suburban community, and another in a rural area.

The researchers reviewed the prescribing history of 51 of the providers over the previous year, focusing on opioids (but excluding Schedule V drugs such as cough medicines or antidiarrheals). "To account for differences in formulation, potency, pill strength, and dosing frequency," they write, "we calculated the total morphine milligram equivalents for each opioid prescription."

They then presented each provider with a graph showing the rate of opioid prescriptions for the department, and asked them to estimate where they fall.

"For most providers, we identified striking gaps in prescribing self-awareness," the researchers report. "Among all intervention participants, 73 percent of attending physicians and advanced practice providers (that is, nurse practitioners and physicians' assistants), and 27 percent of residents, (significantly) underestimated their prescribing rank among their peers."

In contrast, "only five providers—three residents and two attendings—consistently overestimated" where they stood in relation to their colleagues.

The encouraging news is that confronting them with their actual data made a difference in their subsequent prescribing behavior.

"After seeing their real data," Michael reports, "the people with inaccurate self-perceptions, on average, had 2.1 fewer opioid prescriptions per 100 patients six months later." That number increased slightly, to 2.2 fewer prescriptions, after 12 months.

"It is likely that most emergency department providers view their opioid prescribing as similar to, or less than, their peers," the researchers conclude. Shattering that illusion appears to have spurred "robust behavior change for a subset of providers who may have otherwise had difficulty internalizing the need to change."

While this is a small study, it could easily be replicated in emergency rooms across the country. And given estimates that only 5 percent of opioid prescriptions emerge from such settings, it's worth considering how this intervention could be applied to other physicians as well.

A lot of doctors, it seems, suffer from Lake Wobegon syndrome. But in truth, when it comes to careful prescription of opioids, not every practitioner is above average.