中文摘要
初级保健是使用最频繁的医疗服务，美国开具的阿片类药物处方中近一半来自初级保健。本文研究接触阿片类药物处方率较高的初级保健服务提供者（PCP）对阿片类药物使用、阿片类药物使用障碍和心理健康的影响。我们使用电子健康记录，利用医疗机构内部将阿片类药物处方倾向不同的服务提供者准随机分配给65万名新登记接受退伍军人卫生管理局医疗服务的患者这一安排开展研究。我们发现，被分配给阿片类药物处方率高出2.54个百分点的PCP，会使长期使用阿片类药物的概率增加20%（即0.43个百分点），并使发生阿片类药物使用障碍的概率增加4%（即0.035个百分点）；上述2.54个百分点相当于同一医疗机构内处方率处于第90百分位与第10百分位的服务提供者之间的平均差异。退伍军人的心理健康状况恶化：三年内被诊断为抑郁症的概率增加1.3%（即0.31个百分点）。我们发现，处方行为更谨慎的PCP更多地依赖非阿片类疼痛管理，也更遵循有关纳洛酮分发的临床建议。
Abstract
Primary care is the most frequently utilized health service and is the source of nearly half of all opioids prescribed in the United States. This paper studies the impact of exposure to high prescribing primary care providers (PCP) on opioid use, opioid use disorder, and mental health. Using electronic health records, we exploit within-facility quasi-random assignment of providers, who differ in their opioid prescribing tendency, to 650,000 new patients enrolling in care with the Veterans Health Administration. We find that assignment to a PCP who prescribes opioids at a 2.54 percentage point (pp) higher rate (equivalent to the average difference between a 90th and 10th percentile prescriber within a facility) increases the probability of long-term opioid use by 20% (or 0.43 pp) and development of opioid use disorder by 4% (or 0.035 pp). Veterans’ mental health deteriorates: the three-year likelihood of a depression diagnosis increases by 1.3% (or 0.31 pp). We find that PCPs with more cautious prescribing behavior rely more on non-opioid pain management and adhere more to clinical recommendations on naloxone distribution.