Random Acts of Medicine: The Hidden Forces That Sway Doctors, Impact Patients, and Shape Our Health by Anupam B. Jena & Christopher Worsham

Author:Anupam B. Jena & Christopher Worsham [Jena, Anupam B. & Worsham, Christopher]
Language: eng
Format: epub
Publisher: Knopf Doubleday Publishing Group
Published: 2023-07-11T00:00:00+00:00

In general, as adolescents got older, there was a gradual increase in the probability of being prescribed an opioid—perhaps not surprising under the assumption that doctors would find opioids less risky to prescribe to an older adolescent. But there was a jump—a discontinuity—at age eighteen, the cutoff between “child” and “adult.” Patients aged seventeen years and eleven months received an opioid 13.7 percent of the time, while those aged eighteen years and one month received an opioid 15.3 percent of the time—a 1.6-percentage-point increase. Under a statistical model[*6] that accounted for the gradual increase in prescription rates as well as confounding factors, we estimated this to be closer to a 1.3-percentage-point increase.

In other words, this meant that for adolescents around age eighteen, being labeled an “adult” made them 9.7 percent more likely to receive an opioid than if they had been labeled a “child.” With an estimated 20.2 million ED visits by patients aged fifteen to twenty-four annually in the United States, this difference corresponded to at least tens of thousands of arbitrary opioid prescriptions filled each year.

Opioid pain medications are dangerous, as we all know by now, placing patients at risk of long-term use, addiction, and overdose.[*7] Of course, doctors prescribe them to treat pain when the benefits of pain control are felt to outweigh the risks of the medication. But when such drug prescriptions are influenced by arbitrary factors—in this case, an adolescent’s proximity to adulthood—there’s only risk, no benefit. And if indeed opioids were being prescribed with this arbitrary influence, we should see an increase in adverse events associated with them, right?

We looked at the same group of adolescents, but this time focused on the probability that any one of several major opioid-related adverse events occurred after an ED visit: new long-term opioid use, a new diagnosis of opioid use disorder, or overdose. Fortunately, these events are uncommon following ED visits. We found that in only 1.6 percent of all ED visits did one of these events occur in the year following the visit. But using a statistical model similar to the one used before, we found that being considered an “adult” rather than a “child,” regardless of their true age, was associated with a 0.2-percentage-point increase in the rate of an adverse event, making patients around age eighteen who happened to have been labeled “adults” 12.6 percent more likely to have an adverse event than those labeled a “child.”

Our results showed us a few important things. As noted, adolescents around eighteen were being treated differently in the ED depending on whether they were labeled a “child” or an “adult,” resulting in differing rates of opioid prescriptions and subsequent adverse events. We can’t say for sure what was driving the difference, but we believe it was some combination of representativeness bias on the part of physicians (treating “children” one way and “adults” another) coupled with differences in treatment protocols (when patients go through “pediatric” care systems versus “adult” care systems).

As we continue to grapple with the opioid epidemic, such results can be demoralizing.

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