More opioid prescriptions were written for patients seeing their primary care provider toward the end of the day, according to a study published last month in the Journal of the American Medical Association.

Time pressure influencing doctors’ clinical decision-making is a long-standing concept, yet little empirical research has examined its validity or magnitude, write the researchers of the study Hannah Neprash, Ph.D., and Michael Barnette, M.D.

Specifically, they examined how appointment timing affects prescribing for patients with pain. Their hypothesis — as “the workday progresses and appointments run behind schedule, physicians may be more likely to prescribe opioids in potentially inappropriate situations to simply move on.”

Their findings help illustrate dynamics behind the overprescribing of opioid pain relievers, which has been associated with the sharp increase in opioid addiction over the past three decades and is a major contributor to the national crisis of opioid use disorder and overdose.

Preliminary 2018 numbers released in July by the Centers for Disease Control and Prevention show the first waning of the epidemic in over a decade, with a 4.2% drop nationwide for overdose-related deaths.

Time pressure resulting in more prescriptions

The researchers used records from 2017 of 678,319 appointments with 5,603 primary care physicians on the Athenahealth network. The patients selected reported a new, painful condition such as back pain, headache, joint disease or fibromyalgia but no observable long-term use of opioids.

The results showed physicians prescribed opioids in 4% of the first three appointments of the day, as opposed to in 5.3% of the 19th through 21st appointments. This corresponds to a 33% increase.

"If the opioid prescribing rate for the first three visits had held constant throughout the day, there would’ve been 4,459 fewer opioid prescriptions in 2017," illustrate the authors.

Additionally, there was a 17% relative increase in opioid prescriptions when appointments ran an hour or more behind schedule.

Burnout affecting clear decision-making

Interestingly, this isn’t the first study to link appointment time with potentially inappropriate prescribing. A 2014 study examining antibiotic prescribing tendencies for acute respiratory infections, a condition not requiring antibiotics, similarly showed increased prescriptions at the end of the workday.

“Even something routine, such as prescribing an antibiotic, is influenced not by particularly dramatic degrees of sleep deprivation but by physicians just getting tired over a period of time,” commented lead author physician Jeffrey A. Linder in a Pharmaceutical Journal article.

These examples point to the workload challenges and systemic issues wearing physicians down.

“Many physicians in busy primary care practices feel like they are playing a never-ending game of Whack-a-Mole,” writes Dr. Steven Adelman, director of Physician Health Services, a nonprofit that promotes the health and well-being for physicians and medical students in Massachusetts.

Indeed, the pressure faced by today’s physicians is extremely high. In 2019 Medscape survey of 15,000 US doctors, 44% reported feeling burnout, defined here as “unresolvable job stress that leads to exhaustion and feeling overwhelmed, cynical and detached from the job.”

Earlier in the day and when appointments are running on schedule, physicians are more likely to invest the extra time needed to explain non-opioid alternatives for pain management note the opioid study researchers.

Challenges in distinguishing legit patients from abusers

Doctors may avoid the risk of disappointing patients by not giving them the meds they want, conclude authors of both the antibiotic and opioid studies.

Unfortunately, given the highly addictive nature of opioid pain relievers, patient disappointment can escalate, and doctors may find themselves up against wolves in lambs’ clothing.

Telling heart-wrenching stories and refusing to leave without a prescription are tactics cunning opioid addicts use, explains writer Bruce Y. Lee in a Forbes article. Scheduling appointments to target doctors at the end of an exhausting day wasn’t listed, but it follows the same line of logic.

Indeed, one weakness of the study was that it only included data from the Athenahealth system. Therefore, some patients identified as having no prior opioid use may have received them outside that network.

Regularly switching doctors is another trick addicts use. “Opioid abusers often will see multiple doctors so that they cannot be easily tracked,” reports Lee.

Pain tries patients’ patience

Another weakness of the study was that the data didn’t include information about pain severity nor the effectiveness of earlier treatments. The researchers therefore had no way of knowing whether the opioid pain relievers were prescribed appropriately.

As one reader of the study who identified herself as a chronic pain sufferer commented, pain increases as the day wears on and a doctor’s office isn’t the most comfortable place to be when you’re in pain.

If it’s late in the day or the doctor is running an hour or more behind schedule, by the time the patient sees the doctor, his or her pain may be legitimately worse and the patient more emphatic about getting a quick and immediate solution. The doctor recommending a series of physical therapy sessions to address the root cause isn’t likely to please the patient at that point.