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

While 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 US 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% CI: [17%, 42%]). An instrumental variable analysis accounting for omitted variable and self-selection bias indicates this may be 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 or when the patient saw their regular provider (versus another clinician) during the early stages of opioid use. Overall, our analysis indicates that systematic, operational changes in the early stages of managing new opioid patients may be a promising, and hitherto overlooked, opportunity to curb the opioid epidemic