Journal of General Internal Medicine

, Volume 34, Issue 8, pp 1522–1529 | Cite as

Emergency Physician Opioid Prescribing and Risk of Long-term Use in the Veterans Health Administration: an Observational Analysis

  • Michael L. Barnett
  • Xinhua Zhao
  • Michael J. Fine
  • Carolyn T. Thorpe
  • Florentina E. Sileanu
  • John P. Cashy
  • Maria K. Mor
  • Thomas R. Radomski
  • Leslie R. M. Hausmann
  • Chester B. Good
  • Walid F. GelladEmail author



Treatment by high-opioid prescribing physicians in the emergency department (ED) is associated with higher rates of long-term opioid use among Medicare beneficiaries. However, it is unclear if this result is true in other high-risk populations such as Veterans.


To estimate the effect of exposure to high-opioid prescribing physicians on long-term opioid use for opioid-naïve Veterans.


Observational study using Veterans Health Administration (VA) encounter and prescription data.

Setting and Participants

Veterans with an index ED visit at any VA facility in 2012 and without opioid prescriptions in the prior 6 months in the VA system (“opioid naïve”).


We assigned patients to emergency physicians and categorized physicians into within-hospital quartiles based on their opioid prescribing rates. Our primary outcome was long-term opioid use, defined as 6 months of days supplied in the 12 months subsequent to the ED visit. We compared rates of long-term opioid use among patients treated by high versus low quartile prescribers, adjusting for patient demographic, clinical characteristics, and ED diagnoses.


We identified 57,738 and 86,393 opioid-naïve Veterans managed by 362 and 440 low and high quartile prescribers, respectively. Patient characteristics were similar across groups. ED opioid prescribing rates varied more than threefold between the low and high quartile prescribers within hospitals (6.4% vs. 20.8%, p < 0.001). The frequency of long-term opioid use was higher among Veterans treated by high versus low quartile prescribers, though above the threshold for statistical significance (1.39% vs. 1.26%; adjusted OR 1.11, 95% CI 0.997–1.24, p = 0.056). In subgroup analyses, there were significant associations for patients with back pain (adjusted OR 1.25, 95% CI 1.01–1.55, p = 0.04) and for those with a history of depression (adjusted OR 1.28, 95% CI 1.08–1.51, p = 0.004).


ED physician opioid prescribing varied by over 300% within facility, with a statistically non-significant increased rate of long-term use among opioid-naïve Veterans exposed to the highest intensity prescribers.


opioid emergency prescribing Veteran 


Funding Information

This study is financially supported by a grant from VA Health Services Research & Development (HSR&D) I01 HX001765-01 to Dr. Gellad.

Compliance with Ethical Standards

This study was approved by the institutional review board at the VA Pittsburgh Healthcare System.

Conflict of Interest

Dr. Barnett receives consulting fees unrelated to this work from Greylock McKinnon Associates Inc. and serves as a paid expert witness for plaintiffs in lawsuits against opioid manufacturers and distributors. The authors have no other conflicts of interest to disclose.


This work represents the opinions of the authors alone and does not necessarily represent the views of the Department of Veterans Affairs, the National Institute on Aging, or the US Government.

Supplementary material

11606_2019_5023_MOESM1_ESM.docx (94 kb)
ESM 1 (DOCX 94 kb)


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Copyright information

© Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019

Authors and Affiliations

  • Michael L. Barnett
    • 1
    • 2
  • Xinhua Zhao
    • 3
  • Michael J. Fine
    • 3
    • 4
  • Carolyn T. Thorpe
    • 3
    • 5
  • Florentina E. Sileanu
    • 3
  • John P. Cashy
    • 3
  • Maria K. Mor
    • 3
    • 6
  • Thomas R. Radomski
    • 3
    • 4
  • Leslie R. M. Hausmann
    • 3
    • 4
  • Chester B. Good
    • 3
    • 4
    • 7
  • Walid F. Gellad
    • 3
    • 4
    Email author
  1. 1.Department of Health Policy and Management Harvard T.H. Chan School of Public HealthBostonUSA
  2. 2.Division of General Internal Medicine and Primary Care, Department of MedicineBrigham and Women’s HospitalBostonUSA
  3. 3.Center for Health Equity Research and Promotion (CHERP) VA Pittsburgh Healthcare SystemPittsburghUSA
  4. 4.Department of Medicine, Division of General Internal MedicineUniversity of PittsburghPittsburghUSA
  5. 5.Division of Pharmaceutical Outcomes and PolicyUniversity of North Carolina Eshelman School of PharmacyChapel HillUSA
  6. 6.Department of Biostatistics, Graduate School of Public HealthUniversity of PittsburghPittsburghUSA
  7. 7.Center for High Value Health CareUniversity of Pittsburgh Medical Center (UPMC)PittsburghUSA

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