NPs and Opioid Prescribing: What Don’t We Know?

Ulrike Muench
Ulrike Muench, assistant professor at the UCSF School of Nursing, led one of the first studies on NPs' opioid prescribing habits. (Photo by Elisabeth Fall)

By Andrew Schwartz

As United States policymakers continue to seek ways to halt the opioid epidemic, key pieces of information are missing that could help shape solutions. One of the most glaring examples is the absence of information about nurse practitioner opioid prescribing patterns.  

The information matters because nurse practitioners (NPs) account for the third-largest share of opioids prescribed in primary carethe practice setting that accounts for the largest percentage of opioid prescriptions in the U.S. In rural areas – where NPs are often the only primary care providers providing services to vulnerable populations – the opioid epidemic has been particularly fast-growing.

In an effort to close the gap and open a conversation on NP opioid prescribing, the UCSF School of Nursing’s Ulrike Muench led one of the first studies on the topic, publishing her findings in the June 2019 issue of Medical Care.           

Less Opioids Prescribed, at Higher Doses

The study drew on data from 2009 to 2013 for more than 20,000 Medicare beneficiaries. It compared prescribing patterns of beneficiaries who were managed by NPs with those managed by physicians in states in which NPs are able to prescribe controlled substances without physician oversight.

In brief, the research team found that under NP management, Medicare beneficiaries were less likely to receive an opioid and less likely to be acute users at baseline. However, beneficiaries who did receive opioids were more likely to receive a high daily opioid dose of morphine milligram equivalent (MME) greater than 100 milligrams compared to physician-managed beneficiaries.

Given the scope of opioid misuse, it was encouraging that patients seen by NPs received fewer opioids and even with regards to the higher daily MME dose, Muench notes, “We should not jump to the conclusion that these findings are true differences in prescribing patterns, since NPs may see more complex patients, or may be more likely to be treating chronic pain patients, but we could not determine that from this particular dataset.”       

“It could be that nurse practitioners treat patients who need higher MMEs; we just don’t know at this point,” says NP and School faculty member Matt Tierney, whose expertise is in substance use treatment. He notes, for example, that in academic medicine settings, advanced practice nurses often have responsibility for complex, chronic care patients because these nurses are a consistent clinical presence, whereas physician residents cycle through.

Another aspect to consider about the study’s findings is that since 2013, new regulations have emerged, there is greater awareness of the opioid epidemic, and in some settings, adoption of electronic health records (EHRs) and computerized order entry have improved how MMEs are calculated.

“Right now, however, there is little information on the extent to which EHRs have adopted MME calculations and other flags and dose restrictions to alert providers, though there are studies underway testing different EHR specifications,” says Muench. “In the long run, I think EHRs will help prescribers identify MMEs and the overlap of opioids and benzodiazepine prescriptions in such a way that we will hopefully see minimal variation in prescribing patterns. There is already evidence that prescriptions nationally of high MMEs are dropping since 2016.”

Read the full story in our Science of Caring publication.