Emergency department opioid prescribing trends among provider types: An analysis of the NHAMCS, 2019-2021

Emergency department opioid prescribing trends among provider types: An analysis of the NHAMCS, 2019-2021 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Emergency department opioid prescribing trends among provider types: An analysis of the NHAMCS, 2019-2021 Carrson French, Jace Jackson, Zach Monahan, Kelly Murray, Micah Hartwell This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5363264/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 31 Mar, 2025 Read the published version in Internal and Emergency Medicine → Version 1 posted 4 You are reading this latest preprint version Abstract Background Despite efforts to mitigate high opioid prescription frequencies, previous research showed minimal change within emergency departments (ED) in the United States, and few studies investigate prescription provider types. Thus, our primary objective was to assess opioid prescribing rates by differing healthcare team members using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Methods Using the 2019–2021 NHAMCS, we calculated the overall opioid prescription rate during ED visits by provider type. Next, we estimated opioid prescription rates by provider type annually and determined differences by year using design-based X 2 tests and regression models. Results From 2019 through 2021, 7,428 of 50,548 visits involved opioids, representing 15.62% of all ED visits. During this timeframe, 16.59% of total encounters with opioid prescriptions were among attending/consulting physicians. This was followed by physician assistants (13.91%), nurse practitioners (10.67%), and residents (7.28%). Compared to 2019, opioid prescribing rates showed no significant changes; however, resident physicians showed a significant decrease, and RNs showed a significant increase. Discussion From our analysis, opioid prescribing rates in the ED were highest among attending/consulting physicians, and rates among physician assistants and nurse practitioners were higher than 10%. Resident physicians had a significant decrease in opioid prescriptions, while RNs had an increase—likely due to new laws enacted during this timeframe. Removing barriers to alternative pain management for acute and long-term care may lessen rates of opioid prescriptions—including patient and provider training, physical therapists inclusion, and osteopathic manipulative therapy incorporation. NHAMCS Provider Opioids Prescribing Emergency Department (EDs) Figures Figure 1 Introduction The chronic use of opioids and their addictive properties can have multiple negative impacts on patients' lives. However, they may be necessary in the course of medical treatment for acute and chronic pain. Opioid overuse and opioid dependence are linked to many comorbidities, from delayed gastric emptying, constipation, QT prolongation, or Torsades de Pointes, to increased opioid tolerance, and opioid-related drug overdoses [ 1 ]. In addition to receiving opioids while in the emergency departments (EDs) for traumatic injuries, individuals may also turn to EDs for opioid prescriptions for the treatment of acute pain, chronic pain related to their health conditions, or lack of a primary care physician [ 2 ]. This results in EDs being a significant source of opioid prescriptions [ 3 ]. The shortage of practicing primary care physicians in the United States—due to a higher demand for healthcare than our current training system can accommodate [ 4 ]—may be a factor for individuals turning to EDs for pain treatment. With the demand for emergency room services and an increasing shortage of emergency room physicians, there has been an increase in the number of advanced practice providers treating patients in the EDs [ 5 ]. Advanced practice providers, such as nurse practitioners (NPs) and physician assistants (PAs), are qualified individuals who can treat, diagnose, and prescribe medications to the patients they see; however, there are variations as to what classes of medications each provider type can prescribe, as well as limitations in quantity and duration of prescription, based on specific state laws [ 3 ]. By 2017, all 50 states, including Washington D.C., had either operational Prescription Drug Monitoring Programs (PDMP) or had passed legislation to operate PDMPs [ 6 ]—though regulations vary by state [ 7 ]. Further, the COVID-19 pandemic disrupted the continuity of medical care, which may have impacted prescribing patterns in both primary care and ED settings. A 2021 study by Price et al., found that physicians and NPs received the most exposure to training on proper prescribing; however, all provider types included in the study mentioned that state resources (e.g., PDMPs, required coursework) and continuing education related to opioid prescription guidelines were helpful [ 8 ]. Another study using machine learning algorithms identified patterns that determined the likelihood of opioids being prescribed in EDs—finding that individuals who were white, female, or near 45 years of age were more likely to be prescribed opioids. Other significant factors increasing the likelihood of opioid prescribing included when a computed tomography (CT) scan was ordered or if the patient had a complaint of abdominal pain or back pain [ 9 ]. A previous study by Yang et al. assessed differing rates of opioid prescription by provider type using data from 2005 to 2015 [ 3 ]. Given multiple changes have occurred since that time, including the COVID-19 pandemic and multiple laws regulating when an opioid may be prescribed and by whom, our primary objective was to assess the rate at which opioids were prescribed to individuals seen in the EDs from 2019 through 2021 by differing members of the healthcare team. To conduct this study, we used data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). In addition to updating the literature following the implementation of opioid prescribing laws, we will also include additional provider types not included by Yang, et al [ 3 ]—specifically resident physicians who are overseen by a licensed, attending physician who may potentially factor into initial patient exposure to opioids [ 10 ]. Methods Data Source We performed a cross-sectional analysis of the NHAMCS using data from the 2019 through 2021 data cycles. The NHAMCS is a national survey that collects dependable data related to ambulatory services provided in all 50 states and the District of Columbia. Surveys are completed by trained administration staff for hospital visits within EDs, noninstitutional hospitals, and short-stay hospitals [ 11 ]. The survey excludes all federal, military, and Veterans Affairs (VA) hospitals. The data collection times are randomly assigned in 4-week recording periods at the selected hospitals. Hospital sampling is broken down into a 3 stage process—first, selecting geographical areas, followed by identifying available hospitals in each geographic region, and then selecting the emergency services data that is accessible and pertinent to the survey. The data sampling consists of computerized information, including race, ethnicity, age, gender, chief complaint, physician diagnosis, hospital orders, and planned treatments. Inclusion Criteria Variables included in our study were all ED visits and whether or not an opioid was prescribed to the patient. The list of opioids that we screened within the NHAMCS data included oxycodone, oxymorphone, hydrocodone, hydromorphone, fentanyl, morphine, methadone, and tramadol. Screening for the study included combination medications (e.g., oxycodone/acetaminophen) and varying doses. Additionally, only visits that listed the type of provider seen during the visit were included. These types included “Emergency department attending physician,” “Emergency department resident or intern,” “Consulting physician,” “Nurse practitioner,” “Physician assistant,” and “Register Nurse.” Visits missing this data were excluded from the analysis. Statistical analysis We first estimated the overall rates of opioids prescribed during the timeframe and by provider type. Next, we calculated the estimated rates of opioids prescribed by provider type within each year’s data. Differences in prescribing rate overall and by year were calculated using design-based chi-squared tests. Differences in annual trends within provider type were tested using regression models. All analyses employed the survey design and sampling weights, provided by NHAMCS, which were adjusted for multiple years of data for relevant analyses. Alpha was set at 0.05 for all tests that were conducted using Stata 16.1 (StataCorp LLC., College Station, TX). Results From 2019 through 2021, 7,428 of 50,548 visits had an opioid prescribed or administered, representing 15.62% of all ED visits. During this timeframe, the frequency of opioid prescriptions was highest among attending/consulting physicians (16.59%). This was followed by physician assistants at 13.9%, nurse practitioners at 10.67%, and residents at 7.28% (Table 1 ). Table 1 Percent of visits where opioids were prescribed, by type of provider seen Overall 2019 2020 2021 Variable n (%) n (%) n (%) n (%) Level of Provider Attending/consulting physician 6620 (16.59) 2572 (17.21) 1955 (16.69) 2093 (15.85) Resident 70 (7.28) 44 (11.48) 19 (5.72)* 7 (3.07)** NP 248 (10.67) 127 (11.50) 72 (10.66) 49 (9.41) PA 429 (13.91) 172 (13.81) 136 (15.13) 121 (12.87) RN 52 (3.81) 13 (2.725) 27 (7.617)* 12 (1.707) Other provider seen 3 (0.57) 0 (0) 2 (1.355) 1 (0.08) No provider seen 6 (5.65) 2 (4.63) 3 (6.20) 1 (6.33) Total 7428 (15.62) 2930 (16.20) 2214 (15.81) 2284 (14.83) Significant findings for trends in group with reference being 2019: * P < .05, ** P < .01 The rates of prescribing opioids by provider type were statistically different over the 2019–2021 timeframe (X2 = 21.63, P < .0001)—as well as each individual year—with attending and consulting physicians having higher rates of opioid prescriptions compared to other types of providers in the study. Over the 2019 to 2021 timeframe, overall rates of opioid prescriptions in our sample decreased, though these changes were not statistically significant. However, for the individual provider types, residents’ rates of prescribing significantly decreased from 11.48% of visits in 2019 to 5.72% in 2020 (p = .029) and 3.07% in 2021 (p = .003). The only type to show a significant increase in any year were RNs, whose rates of prescribing opioids increased from 2.73% in 2019 to 7.62% in 2020 (p = .024; Fig. 1 ). No other groups showed any significant change by year. Discussion From our analysis, we found there has been an overall decrease in the number of opioid prescriptions seen among ED visits from 2019 to 2021. While this general reduction was not statistically significant, our analysis showed discrete significant differences in rates of opioid prescriptions from 2019 to 2021 among RNs and Resident Physicians. Our results showed rates of prescribing opioids in the ED were highest among attending or consulting physicians. The early phase of the COVID-19 pandemic may have also disrupted trends among PAs, RNs, and residents, as the former two showed an increase in opioid prescribing rates during 2020, and the latter showed a decrease, though only the increased rates of RNs’ prescribing in 2020 was statistically significant. Past research into the impact of the COVID-19 pandemic on people with pre-existing pain does suggest an increased pain burden due to physical and social isolation, as well as decreased medical access during the pandemic [ 12 ]. This may have increased opioid prescription-seeking in some populations. Our results align with other studies showing opioids are most often prescribed by physicians—given these are Schedule II drugs, most states restrict prescription rights solely to this group [ 3 ]. However, this study also supports our findings with PAs’ and NPs’ rates of prescribing opioids [ 3 ]. Based on the data from 2019 to 2021, we found that resident physicians had a significant decrease in the number of opioids prescribed, which is an improvement compared to past studies with a greater number of opioid prescriptions by resident physicians [ 3 ]. Compared to other studies, our findings show a continued trend of decreasing numbers of opioid prescriptions from physicians [ 3 ], though we found an increase in the rate from RNs and PAs. Another study using data from 2006–2010 found there was no significant change in opioid prescriptions during that period [ 13 ]. Our results show supporting evidence that improved regulation of opioid prescriptions in the United States (e.g., PDMPs) may be leading to a decrease in opioid prescriptions in the ED. Implications and recommendations The significant decrease in the rates of opioid prescriptions from resident physicians in this timeframe identifies a key group for understanding future reductions in opioid overprescribing. Previous studies into Resident Physicians’ opioid prescriptions reveal little benefit from best-practice supplemental resources, rather that most prescription decisions are based on standard order sets, attending preference, and the patient’s history of opioid use [ 14 ]. Therefore, monitoring the usage and reevaluating the indications for order sets, which include opioids, could serve as a key intervention in decreasing unnecessary opioid prescriptions. Furthermore, education on supplemental resources and alternatives to opioid prescriptions for training physicians may reduce opioid prescriptions throughout their careers. Such educational programs have been shown to be effective in reducing opioid prescribing as first-line among residents for migraine treatment, joint pain, and various surgical procedures [ 15 ]. For non-physician providers (NPs and PAs), previous research has demonstrated similar rates of opioid prescribing as physicians with some high-prescribing outliers [ 16 ]. Continued monitoring of opioid prescribing rates by individual providers can identify outliers and provide targeted education as needed. Heightened risk of opioid exposure and use increases the need for preventive misuse and treatment due to their addictive nature. Additional complications include the physical, mental, and financial burden that accompany longer-duration opioid prescriptions—especially when other pain management options may be available [ 1 ]. Removing barriers to alternative pain management for acute and long-term care may lessen rates of opioid prescriptions—including patient and provider training, inclusion of physical therapists, and incorporating osteopathic manipulative therapy within the ED [ 13 ]. Patients could also be empowered to learn about the use of these prescriptions and discontinuation of these medications sooner rather than later if appropriate for their condition [ 17 ]. Limitations and Future Research The NHAMCS is a large nationally representative data set collected by the CDC, which provides robust information; however, a limitation of the data is that it is collected from hospitals’ health records [ 11 ]. This provides two potential means for data errors—first, the data is provided to the CDC by hospital administration introducing human error, and second, as the data is from hospital records, only data in the reports is available rather than collecting data directly from the patient or healthcare provider. A relatively small number of participating hospitals also resulted in small sample sizes for some analysis subgroups, which limits our data's generalizability. Additionally, opioid prescription laws vary from state to state, so while our findings are generalizable to national rates, individual hospitals may have differing rates of opioid prescribing by provider type. Future research at the hospital level could investigate not only rates of opioid prescriptions but also the dosage and duration of the prescription within their location and correlated factors such as the years of experience a healthcare provider has, as well as, the types of training in pain management therapy providers need to decrease reliance on opioid prescriptions. Conclusion This study showed that the rate of overall opioid prescriptions made in EDs declined from 2019 through 2021 and that the majority are made by physicians. However, the rates of prescribing or administering opioids among PAs and registered nurses increased during this time—which was likely due to complications emerging from the COVID-19 pandemic in 2020. Increased training in opioid prescribing and alternative pain management strategies may be valuable to all prescriber groups, and in particular, those who show increased trends in prescribing. The overall reduction in opioid prescriptions in the ED provides supporting evidence that PDMPs, new laws regulating opioids, and heightened awareness and messaging regarding the risk of misuse may be working within the US. Declarations Author Contributions: Dr. Hartwell had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Hartwell, French, Jackson; Acquisition, analysis, or interpretation of data: Hartwell; Drafting of the manuscript: Hartwell, French, Jackson; Critical revision of the manuscript for important intellectual content: Murray, Monahan; Ethical Statement: This study was determined to be non-human subjects research by the Oklahoma State University Institutional Review Board. This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Conflicts of interest/Declarations: Dr. Hartwell receives research funding from the National Institute of Child Health and Human Development (U54HD113173; Shreffler), Human Resources Services Administration (U4AMC44250-01-02, PI: Audra Haney; R41MC45951 PI: Hartwell), and previously from the National Institute of Justice (2020-R2-CX-0014 PI: Beaman). Funding: This study was not funded. References Benyamin R, Trescot AM, Datta S, Buenaventura R, Adlaka R, Sehgal N et al (2008) Opioid complications and side effects. Pain Physician 11(2 Suppl):S105–S120 Brasseur E, Gilbert A, Servotte JC, Donneau AF, D’Orio V, Ghuysen A (2021) Emergency department crowding: why do patients walk-in? Acta Clin Belg 76(3):217–223 Yang BK, Storr CL, Trinkoff AM, Sohn M, Idzik SK, McKinnon M (2019) National opioid prescribing trends in emergency departments by provider type: 2005–2015. Am J Emerg Med 37(8):1439–1445 Zhang X, Lin D, Pforsich H, Lin VW (2020) Physician workforce in the United States of America: forecasting nationwide shortages. Hum Resour Health 18(1):8 Wu F, Darracq MA (2020) Physician assistant and nurse practitioner utilization in U.S. emergency departments, 2010 to 2017. Am J Emerg Med 38(10):2060–2064 Puac-Polanco V, Chihuri S, Fink DS, Cerdá M, Keyes KM, Li G (2020) Prescription Drug Monitoring Programs and Prescription Opioid-Related Outcomes in the United States. Epidemiol Rev 42(1):134–153 National Center for Injury Prevention and Control. Integrating & Expanding Prescription Drug Monitoring Program Data: Lessons from Nine States [Internet]. CDC (2017) Feb https://stacks.cdc.gov/view/cdc/45241 Price SM, O’Donoghue AC, Rizzo L, Sapru S, Aikin KJ (2021 Jul-Aug) Opioid Education and Prescribing Practices. J Am Board Fam Med 34(4):802–807 McCann-Pineo M, Ruskin J, Rasul R, Vortsman E, Bevilacqua K, Corley SS et al (2021) Predictors of emergency department opioid administration and prescribing: A machine learning approach. Am J Emerg Med 46:217–224 Hoppe JA, Kim H, Heard K (2015) Association of emergency department opioid initiation with recurrent opioid use. Ann Emerg Med 65(5):493–9e4 Ambulatory Health Care Data [Internet] (2024) [cited 2024 Jun 26]. https://www.cdc.gov/nchs/ahcd/index.htm Shanthanna H, Nelson AM, Kissoon N, Narouze S (2022) The COVID -19 pandemic and its consequences for chronic pain: a narrative review. Anaesthesia 77(9):1039–1050 Kea B, Fu R, Lowe RA, Sun BC (2016) Interpreting the National Hospital Ambulatory Medical Care Survey: United States Emergency Department Opioid Prescribing, 2006–2010. Acad Emerg Med 23(2):159–165 Coughlin JM, Terranella SL, Ritz EM, Xu TQ, Tierney JF, Velasco JM et al (2023) Understanding opioid prescribing practices of resident physicians. Am Surg 89(5):1554–1560 Acharya PP, Fram BR, Adalbert JR, Oza A, Palvannan P, Nardone E et al (2022) Impact of an educational intervention on the opioid knowledge and prescribing behaviors of resident physicians. Cureus 14(3):e23508 Lozada MJ, Raji MA, Goodwin JS, Kuo YF (2020) Opioid prescribing by primary care providers: A cross-sectional analysis of nurse practitioner, physician assistant, and physician prescribing patterns. J Gen Intern Med 35(9):2584–2592 Khorfan R, Shallcross ML, Yu B, Sanchez N, Parilla S, Coughlin JM et al (2020) Preoperative patient education and patient preparedness are associated with less postoperative use of opioids. Surgery 167(5):852–858 Cite Share Download PDF Status: Published Journal Publication published 31 Mar, 2025 Read the published version in Internal and Emergency Medicine → Version 1 posted Reviewers agreed at journal 14 Jan, 2025 Reviewers invited by journal 14 Jan, 2025 Editor assigned by journal 21 Nov, 2024 First submitted to journal 20 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5363264","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":401983177,"identity":"ba7394d3-65f7-4c9e-ac70-604d60d1a80a","order_by":0,"name":"Carrson French","email":"data:image/png;base64,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","orcid":"https://orcid.org/0009-0007-7117-0428","institution":"Oklahoma State University Center for Health Sciences","correspondingAuthor":true,"prefix":"","firstName":"Carrson","middleName":"","lastName":"French","suffix":""},{"id":401983178,"identity":"807b9e09-74ab-4bcf-bd9d-08101666ed1e","order_by":1,"name":"Jace Jackson","email":"","orcid":"","institution":"Oklahoma State University Center for Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Jace","middleName":"","lastName":"Jackson","suffix":""},{"id":401983179,"identity":"e7ee9a88-83b6-44ad-b661-54c8fa105f05","order_by":2,"name":"Zach Monahan","email":"","orcid":"","institution":"Oklahoma State University Center for Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Zach","middleName":"","lastName":"Monahan","suffix":""},{"id":401983180,"identity":"ad611721-5f39-48fc-9ac8-5a8a218b4524","order_by":3,"name":"Kelly Murray","email":"","orcid":"","institution":"Oklahoma State University Center for Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Kelly","middleName":"","lastName":"Murray","suffix":""},{"id":401983181,"identity":"4a1a533b-bb51-4871-bd37-64330326708e","order_by":4,"name":"Micah Hartwell","email":"","orcid":"","institution":"Oklahoma State University Center for Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Micah","middleName":"","lastName":"Hartwell","suffix":""}],"badges":[],"createdAt":"2024-10-30 19:46:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5363264/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5363264/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11739-025-03923-5","type":"published","date":"2025-03-31T15:56:50+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":73939919,"identity":"42ed7f5c-1221-4986-b9d1-3bf192003508","added_by":"auto","created_at":"2025-01-16 07:49:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":75829,"visible":true,"origin":"","legend":"\u003cp\u003eRates of opioid prescription by provider type over year from the NHAMCS.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5363264/v1/bbf4de13742bb3c0bb91321f.png"},{"id":80081897,"identity":"b47d24d9-a30c-4e32-a399-a2c01afaaa4e","added_by":"auto","created_at":"2025-04-07 15:58:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":470902,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5363264/v1/3379711d-24d8-429e-8a1e-45e0cfe91189.pdf"}],"financialInterests":"","formattedTitle":"Emergency department opioid prescribing trends among provider types: An analysis of the NHAMCS, 2019-2021","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe chronic use of opioids and their addictive properties can have multiple negative impacts on patients' lives. However, they may be necessary in the course of medical treatment for acute and chronic pain. Opioid overuse and opioid dependence are linked to many comorbidities, from delayed gastric emptying, constipation, QT prolongation, or Torsades de Pointes, to increased opioid tolerance, and opioid-related drug overdoses [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In addition to receiving opioids while in the emergency departments (EDs) for traumatic injuries, individuals may also turn to EDs for opioid prescriptions for the treatment of acute pain, chronic pain related to their health conditions, or lack of a primary care physician [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This results in EDs being a significant source of opioid prescriptions [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe shortage of practicing primary care physicians in the United States\u0026mdash;due to a higher demand for healthcare than our current training system can accommodate [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u0026mdash;may be a factor for individuals turning to EDs for pain treatment. With the demand for emergency room services and an increasing shortage of emergency room physicians, there has been an increase in the number of advanced practice providers treating patients in the EDs [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Advanced practice providers, such as nurse practitioners (NPs) and physician assistants (PAs), are qualified individuals who can treat, diagnose, and prescribe medications to the patients they see; however, there are variations as to what classes of medications each provider type can prescribe, as well as limitations in quantity and duration of prescription, based on specific state laws [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBy 2017, all 50 states, including Washington D.C., had either operational Prescription Drug Monitoring Programs (PDMP) or had passed legislation to operate PDMPs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u0026mdash;though regulations vary by state [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Further, the COVID-19 pandemic disrupted the continuity of medical care, which may have impacted prescribing patterns in both primary care and ED settings. A 2021 study by Price et al., found that physicians and NPs received the most exposure to training on proper prescribing; however, all provider types included in the study mentioned that state resources (e.g., PDMPs, required coursework) and continuing education related to opioid prescription guidelines were helpful [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Another study using machine learning algorithms identified patterns that determined the likelihood of opioids being prescribed in EDs\u0026mdash;finding that individuals who were white, female, or near 45 years of age were more likely to be prescribed opioids. Other significant factors increasing the likelihood of opioid prescribing included when a computed tomography (CT) scan was ordered or if the patient had a complaint of abdominal pain or back pain [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA previous study by Yang et al. assessed differing rates of opioid prescription by provider type using data from 2005 to 2015 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Given multiple changes have occurred since that time, including the COVID-19 pandemic and multiple laws regulating when an opioid may be prescribed and by whom, our primary objective was to assess the rate at which opioids were prescribed to individuals seen in the EDs from 2019 through 2021 by differing members of the healthcare team. To conduct this study, we used data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). In addition to updating the literature following the implementation of opioid prescribing laws, we will also include additional provider types not included by Yang, et al [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u0026mdash;specifically resident physicians who are overseen by a licensed, attending physician who may potentially factor into initial patient exposure to opioids [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Source\u003c/h2\u003e \u003cp\u003eWe performed a cross-sectional analysis of the NHAMCS using data from the 2019 through 2021 data cycles. The NHAMCS is a national survey that collects dependable data related to ambulatory services provided in all 50 states and the District of Columbia. Surveys are completed by trained administration staff for hospital visits within EDs, noninstitutional hospitals, and short-stay hospitals [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The survey excludes all federal, military, and Veterans Affairs (VA) hospitals. The data collection times are randomly assigned in 4-week recording periods at the selected hospitals. Hospital sampling is broken down into a 3 stage process\u0026mdash;first, selecting geographical areas, followed by identifying available hospitals in each geographic region, and then selecting the emergency services data that is accessible and pertinent to the survey. The data sampling consists of computerized information, including race, ethnicity, age, gender, chief complaint, physician diagnosis, hospital orders, and planned treatments.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion Criteria\u003c/h3\u003e\n\u003cp\u003eVariables included in our study were all ED visits and whether or not an opioid was prescribed to the patient. The list of opioids that we screened within the NHAMCS data included oxycodone, oxymorphone, hydrocodone, hydromorphone, fentanyl, morphine, methadone, and tramadol. Screening for the study included combination medications (e.g., oxycodone/acetaminophen) and varying doses. Additionally, only visits that listed the type of provider seen during the visit were included. These types included \u0026ldquo;Emergency department attending physician,\u0026rdquo; \u0026ldquo;Emergency department resident or intern,\u0026rdquo; \u0026ldquo;Consulting physician,\u0026rdquo; \u0026ldquo;Nurse practitioner,\u0026rdquo; \u0026ldquo;Physician assistant,\u0026rdquo; and \u0026ldquo;Register Nurse.\u0026rdquo; Visits missing this data were excluded from the analysis.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eWe first estimated the overall rates of opioids prescribed during the timeframe and by provider type. Next, we calculated the estimated rates of opioids prescribed by provider type within each year\u0026rsquo;s data. Differences in prescribing rate overall and by year were calculated using design-based chi-squared tests. Differences in annual trends within provider type were tested using regression models. All analyses employed the survey design and sampling weights, provided by NHAMCS, which were adjusted for multiple years of data for relevant analyses. Alpha was set at 0.05 for all tests that were conducted using Stata 16.1 (StataCorp LLC., College Station, TX).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFrom 2019 through 2021, 7,428 of 50,548 visits had an opioid prescribed or administered, representing 15.62% of all ED visits. During this timeframe, the frequency of opioid prescriptions was highest among attending/consulting physicians (16.59%). This was followed by physician assistants at 13.9%, nurse practitioners at 10.67%, and residents at 7.28% (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePercent of visits where opioids were prescribed, by type of provider seen\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eLevel of Provider\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttending/consulting physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6620 (16.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2572 (17.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1955 (16.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2093 (15.85)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (7.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (11.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (5.72)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (3.07)**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e248 (10.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e127 (11.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72 (10.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49 (9.41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e429 (13.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e172 (13.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e136 (15.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e121 (12.87)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (3.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (2.725)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (7.617)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 (1.707)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther provider seen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (0.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (1.355)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (0.08)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo provider seen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (5.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (4.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (6.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (6.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7428 (15.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2930 (16.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2214 (15.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2284 (14.83)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eSignificant findings for trends in group with reference being 2019: * P\u0026thinsp;\u0026lt;\u0026thinsp;.05, ** P\u0026thinsp;\u0026lt;\u0026thinsp;.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe rates of prescribing opioids by provider type were statistically different over the 2019\u0026ndash;2021 timeframe (X2\u0026thinsp;=\u0026thinsp;21.63, P\u0026thinsp;\u0026lt;\u0026thinsp;.0001)\u0026mdash;as well as each individual year\u0026mdash;with attending and consulting physicians having higher rates of opioid prescriptions compared to other types of providers in the study.\u003c/p\u003e \u003cp\u003eOver the 2019 to 2021 timeframe, overall rates of opioid prescriptions in our sample decreased, though these changes were not statistically significant. However, for the individual provider types, residents\u0026rsquo; rates of prescribing significantly decreased from 11.48% of visits in 2019 to 5.72% in 2020 (p\u0026thinsp;=\u0026thinsp;.029) and 3.07% in 2021 (p\u0026thinsp;=\u0026thinsp;.003). The only type to show a significant increase in any year were RNs, whose rates of prescribing opioids increased from 2.73% in 2019 to 7.62% in 2020 (p\u0026thinsp;=\u0026thinsp;.024; Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). No other groups showed any significant change by year.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eFrom our analysis, we found there has been an overall decrease in the number of opioid prescriptions seen among ED visits from 2019 to 2021. While this general reduction was not statistically significant, our analysis showed discrete significant differences in rates of opioid prescriptions from 2019 to 2021 among RNs and Resident Physicians. Our results showed rates of prescribing opioids in the ED were highest among attending or consulting physicians. The early phase of the COVID-19 pandemic may have also disrupted trends among PAs, RNs, and residents, as the former two showed an increase in opioid prescribing rates during 2020, and the latter showed a decrease, though only the increased rates of RNs\u0026rsquo; prescribing in 2020 was statistically significant. Past research into the impact of the COVID-19 pandemic on people with pre-existing pain does suggest an increased pain burden due to physical and social isolation, as well as decreased medical access during the pandemic [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This may have increased opioid prescription-seeking in some populations.\u003c/p\u003e \u003cp\u003eOur results align with other studies showing opioids are most often prescribed by physicians\u0026mdash;given these are Schedule II drugs, most states restrict prescription rights solely to this group [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, this study also supports our findings with PAs\u0026rsquo; and NPs\u0026rsquo; rates of prescribing opioids [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Based on the data from 2019 to 2021, we found that resident physicians had a significant decrease in the number of opioids prescribed, which is an improvement compared to past studies with a greater number of opioid prescriptions by resident physicians [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Compared to other studies, our findings show a continued trend of decreasing numbers of opioid prescriptions from physicians [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], though we found an increase in the rate from RNs and PAs. Another study using data from 2006\u0026ndash;2010 found there was no significant change in opioid prescriptions during that period [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Our results show supporting evidence that improved regulation of opioid prescriptions in the United States (e.g., PDMPs) may be leading to a decrease in opioid prescriptions in the ED.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eImplications and recommendations\u003c/h2\u003e \u003cp\u003eThe significant decrease in the rates of opioid prescriptions from resident physicians in this timeframe identifies a key group for understanding future reductions in opioid overprescribing. Previous studies into Resident Physicians\u0026rsquo; opioid prescriptions reveal little benefit from best-practice supplemental resources, rather that most prescription decisions are based on standard order sets, attending preference, and the patient\u0026rsquo;s history of opioid use [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Therefore, monitoring the usage and reevaluating the indications for order sets, which include opioids, could serve as a key intervention in decreasing unnecessary opioid prescriptions. Furthermore, education on supplemental resources and alternatives to opioid prescriptions for training physicians may reduce opioid prescriptions throughout their careers. Such educational programs have been shown to be effective in reducing opioid prescribing as first-line among residents for migraine treatment, joint pain, and various surgical procedures [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. For non-physician providers (NPs and PAs), previous research has demonstrated similar rates of opioid prescribing as physicians with some high-prescribing outliers [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Continued monitoring of opioid prescribing rates by individual providers can identify outliers and provide targeted education as needed.\u003c/p\u003e \u003cp\u003eHeightened risk of opioid exposure and use increases the need for preventive misuse and treatment due to their addictive nature. Additional complications include the physical, mental, and financial burden that accompany longer-duration opioid prescriptions\u0026mdash;especially when other pain management options may be available [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Removing barriers to alternative pain management for acute and long-term care may lessen rates of opioid prescriptions\u0026mdash;including patient and provider training, inclusion of physical therapists, and incorporating osteopathic manipulative therapy within the ED [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Patients could also be empowered to learn about the use of these prescriptions and discontinuation of these medications sooner rather than later if appropriate for their condition [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eLimitations and Future Research\u003c/h3\u003e\n\u003cp\u003eThe NHAMCS is a large nationally representative data set collected by the CDC, which provides robust information; however, a limitation of the data is that it is collected from hospitals\u0026rsquo; health records [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This provides two potential means for data errors\u0026mdash;first, the data is provided to the CDC by hospital administration introducing human error, and second, as the data is from hospital records, only data in the reports is available rather than collecting data directly from the patient or healthcare provider. A relatively small number of participating hospitals also resulted in small sample sizes for some analysis subgroups, which limits our data's generalizability. Additionally, opioid prescription laws vary from state to state, so while our findings are generalizable to national rates, individual hospitals may have differing rates of opioid prescribing by provider type. Future research at the hospital level could investigate not only rates of opioid prescriptions but also the dosage and duration of the prescription within their location and correlated factors such as the years of experience a healthcare provider has, as well as, the types of training in pain management therapy providers need to decrease reliance on opioid prescriptions.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study showed that the rate of overall opioid prescriptions made in EDs declined from 2019 through 2021 and that the majority are made by physicians. However, the rates of prescribing or administering opioids among PAs and registered nurses increased during this time\u0026mdash;which was likely due to complications emerging from the COVID-19 pandemic in 2020. Increased training in opioid prescribing and alternative pain management strategies may be valuable to all prescriber groups, and in particular, those who show increased trends in prescribing. The overall reduction in opioid prescriptions in the ED provides supporting evidence that PDMPs, new laws regulating opioids, and heightened awareness and messaging regarding the risk of misuse may be working within the US.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003eDr. Hartwell had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Hartwell, French, Jackson; Acquisition, analysis, or interpretation of data: Hartwell; Drafting of the manuscript: Hartwell, French, Jackson; Critical revision of the manuscript for important intellectual content: Murray, Monahan;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Statement:\u0026nbsp;\u003c/strong\u003eThis study was determined to be non-human subjects research by the Oklahoma State University Institutional Review Board. This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest/Declarations:\u0026nbsp;\u003c/strong\u003eDr. Hartwell receives research funding from the National Institute of Child Health and Human Development (U54HD113173; Shreffler), Human Resources Services Administration (U4AMC44250-01-02, PI: Audra Haney; R41MC45951 PI: Hartwell), and previously from the National Institute of Justice (2020-R2-CX-0014 PI: Beaman).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis study was not funded.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBenyamin R, Trescot AM, Datta S, Buenaventura R, Adlaka R, Sehgal N et al (2008) Opioid complications and side effects. Pain Physician 11(2 Suppl):S105\u0026ndash;S120\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrasseur E, Gilbert A, Servotte JC, Donneau AF, D\u0026rsquo;Orio V, Ghuysen A (2021) Emergency department crowding: why do patients walk-in? Acta Clin Belg 76(3):217\u0026ndash;223\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang BK, Storr CL, Trinkoff AM, Sohn M, Idzik SK, McKinnon M (2019) National opioid prescribing trends in emergency departments by provider type: 2005\u0026ndash;2015. Am J Emerg Med 37(8):1439\u0026ndash;1445\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang X, Lin D, Pforsich H, Lin VW (2020) Physician workforce in the United States of America: forecasting nationwide shortages. Hum Resour Health 18(1):8\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu F, Darracq MA (2020) Physician assistant and nurse practitioner utilization in U.S. emergency departments, 2010 to 2017. Am J Emerg Med 38(10):2060\u0026ndash;2064\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePuac-Polanco V, Chihuri S, Fink DS, Cerd\u0026aacute; M, Keyes KM, Li G (2020) Prescription Drug Monitoring Programs and Prescription Opioid-Related Outcomes in the United States. Epidemiol Rev 42(1):134\u0026ndash;153\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Center for Injury Prevention and Control. Integrating \u0026amp; Expanding Prescription Drug Monitoring Program Data: Lessons from Nine States [Internet]. CDC (2017) Feb \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://stacks.cdc.gov/view/cdc/45241\u003c/span\u003e\u003cspan address=\"https://stacks.cdc.gov/view/cdc/45241\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrice SM, O\u0026rsquo;Donoghue AC, Rizzo L, Sapru S, Aikin KJ (2021 Jul-Aug) Opioid Education and Prescribing Practices. J Am Board Fam Med 34(4):802\u0026ndash;807\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCann-Pineo M, Ruskin J, Rasul R, Vortsman E, Bevilacqua K, Corley SS et al (2021) Predictors of emergency department opioid administration and prescribing: A machine learning approach. Am J Emerg Med 46:217\u0026ndash;224\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoppe JA, Kim H, Heard K (2015) Association of emergency department opioid initiation with recurrent opioid use. 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Surgery 167(5):852\u0026ndash;858\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"internal-and-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iaem","sideBox":"Learn more about [Internal and Emergency Medicine](http://link.springer.com/journal/11739)","snPcode":"11739","submissionUrl":"https://www.editorialmanager.com/iaem/default.aspx","title":"Internal and Emergency Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"NHAMCS, Provider, Opioids, Prescribing, Emergency Department (EDs)","lastPublishedDoi":"10.21203/rs.3.rs-5363264/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5363264/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDespite efforts to mitigate high opioid prescription frequencies, previous research showed minimal change within emergency departments (ED) in the United States, and few studies investigate prescription provider types. Thus, our primary objective was to assess opioid prescribing rates by differing healthcare team members using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eUsing the 2019\u0026ndash;2021 NHAMCS, we calculated the overall opioid prescription rate during ED visits by provider type. Next, we estimated opioid prescription rates by provider type annually and determined differences by year using design-based \u003cem\u003eX\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e tests and regression models.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFrom 2019 through 2021, 7,428 of 50,548 visits involved opioids, representing 15.62% of all ED visits. During this timeframe, 16.59% of total encounters with opioid prescriptions were among attending/consulting physicians. This was followed by physician assistants (13.91%), nurse practitioners (10.67%), and residents (7.28%). Compared to 2019, opioid prescribing rates showed no significant changes; however, resident physicians showed a significant decrease, and RNs showed a significant increase.\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e \u003cp\u003eFrom our analysis, opioid prescribing rates in the ED were highest among attending/consulting physicians, and rates among physician assistants and nurse practitioners were higher than 10%. Resident physicians had a significant decrease in opioid prescriptions, while RNs had an increase\u0026mdash;likely due to new laws enacted during this timeframe. Removing barriers to alternative pain management for acute and long-term care may lessen rates of opioid prescriptions\u0026mdash;including patient and provider training, physical therapists inclusion, and osteopathic manipulative therapy incorporation.\u003c/p\u003e","manuscriptTitle":"Emergency department opioid prescribing trends among provider types: An analysis of the NHAMCS, 2019-2021","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-16 07:49:12","doi":"10.21203/rs.3.rs-5363264/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2025-01-14T11:42:15+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-01-14T11:35:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-21T12:18:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"Internal and Emergency Medicine","date":"2024-11-20T12:33:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"internal-and-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iaem","sideBox":"Learn more about [Internal and Emergency Medicine](http://link.springer.com/journal/11739)","snPcode":"11739","submissionUrl":"https://www.editorialmanager.com/iaem/default.aspx","title":"Internal and Emergency Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"13910fce-2e38-4398-91e5-17a35c539023","owner":[],"postedDate":"January 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-07T15:58:07+00:00","versionOfRecord":{"articleIdentity":"rs-5363264","link":"https://doi.org/10.1007/s11739-025-03923-5","journal":{"identity":"internal-and-emergency-medicine","isVorOnly":false,"title":"Internal and Emergency Medicine"},"publishedOn":"2025-03-31 15:56:50","publishedOnDateReadable":"March 31st, 2025"},"versionCreatedAt":"2025-01-16 07:49:12","video":"","vorDoi":"10.1007/s11739-025-03923-5","vorDoiUrl":"https://doi.org/10.1007/s11739-025-03923-5","workflowStages":[]},"version":"v1","identity":"rs-5363264","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5363264","identity":"rs-5363264","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}