Physicians were more likely to prescribe opioids later in the day and when running behind schedule than when appointments were earlier and on-time, according to a study published in JAMA Network Open.

The aim of the cross-sectional, within-physician study was to assess the relationship of the order of appointments and relative delay in schedule with the likelihood of the physician to prescribe opioids for pain relief. Data were obtained from a claim subset and electronic health record systems from athenahealth, Inc. The rate of opioid prescribing was compared with the rate of nonsteroidal anti-inflammatory drug (NSAID) prescriptions written and physical therapy referrals. This study included primary care, outpatient office appointments involving opioid-naive patients with new painful conditions.

Appointments were grouped into sets of 3 as they progressed throughout the day, starting with appointments 1 through 3 and ending with appointments 19 through 21. Lateness was determined by calculating the difference between the scheduled appointment time and the time-stamp for the physician first encountering the patient. The primary outcome was the rate of opioid prescriptions ordered, but it is unknown if those prescriptions were filled. Secondary outcomes were the rate of prescriptions for NSAIDs written and physical therapy referrals ordered.

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This study included 5603 primary care physicians who saw 642,262 patients during 678,319 appointments. Slots in the first 2 groupings of appointments (appointments 1 through 6) were less likely to be filled by women and patients with chronic conditions. Additionally, patients in these groupings were less likely to have a ≤15-minute appointment (P <.001, for all). When comparing appointments 1 through 3 with appointments 19 through 21, appointments in the later grouping were 1.3% more likely to result in an opioid prescription (4.0% vs 5.3%; P <.001), which represents a 33% relative increase in the rate of opioid prescribing over the course of the day.

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Controlling for appointment start time, appointments starting 0 to 9 minutes later than scheduled had an opioid prescribing rate of 4.4%, and appointments starting ≥60 minutes late had an opioid prescribing rate of 5.2%, which represents an increase of 17% (P <.001). For NSAID prescriptions, the prescribing rate remained steady, with a rate of 14.3% for appointments 1 through 3 and 14.6% for appointments 19 through 21 (P =.12), as well as 14.3% for appointments running 0 to 9 minutes late and 14.4% for appointments running ≥60 minutes late (P =.52). The rate of physical therapy referrals remained fairly steady as well, at 6.8% for appointments 1 through 3 and 6.7% for appointments 19 through 21 (P =.28), as well as 6.8% for both appointments running 0 to 9 minutes late and those running ≥60 minutes late (P =.98).

Limitations of this study include the potential effect of unobserved factors that could lead to an uptick in opioid prescriptions occurring later in the day; the difficulty in assessing actual time pressures experienced by individual physicians throughout the day; the fact that data on a patient’s appointment and treatment may have been incomplete; and the potential for physicians to recommend over-the-counter NSAIDs instead of writing prescriptions for them.

The researchers concluded that “increases in within-physician opioid prescribing for patients with painful conditions were associated with appointments that occurred later in the day and with appointments that were behind schedule. These results are consistent with the concept that time pressure, through multiple possible mechanisms, may influence physician decision-making.”


Neprash HT, Barnett ML. Association of primary care clinic appointment time with opioid prescribing. JAMA Netw Open. 2019;2(8):e1910373.