Curbing the Opioid Epidemic at its Root: The Effect of Provider Discordance after Opioid Initiation

Although medical research has addressed the clinical management of chronic opioid users, little is known about how operational interventions shortly after opioid initiation can impact a patient’s likelihood of long-term opioid use. Using a nationwide U.S. database of medical and pharmaceutical claims, we investigate the care delivery process at the most common entry point to opioid use: the primary care setting. For patients who return to primary care for a follow-up appointment within 30 days of opioid initiation, we ask who should revisit and potentially revise the opioid-based treatment plan: the initial prescriber (provider concordance) or an alternate clinician (provider discordance)? First, using a fully controlled logistic model, we find that provider discordance reduces the likelihood of long-term opioid use 12 months after opioid initiation by 31% (95% Confidence Interval: [18%, 43%]). Both the instrumental variable analysis technique and propensity-score matching (utilizing the minimum-bias estimator approach) account for omitted variable bias and indicate that this is a conservative estimate of the true causal effect. Second, looking at patient activities immediately after the follow-up appointment, we find that this long-term reduction is at least partially explained by an immediate reduction in opioids prescribed after the follow-up appointment. Third, the data suggest that the benefit associated with provider discordance remains significant regardless of whether the patient’s initial prescriber was their regular primary care provider or another clinician. Overall, our analysis indicates that systematic, operational changes in the early stages of managing new opioid patients may offer a promising, and hitherto overlooked, opportunity to curb the opioid epidemic. This paper was accepted by David Simchi-Levi, healthcare management.