Survey of select practice behaviors by primary care physicians on the use of opioids for chronic pain

Abstract

Objective-To assess the use of opioids by primary care physicians for the treatment of chronic pain.Methods-A written survey was completed by 248 primary care physicians. Outcomes of interest included type of opioids prescribed, common pain diagnoses treated, opioid prescribing concerns, treatment of patients with a history of substance use disorders and clinic-based protocols for pain management.Results-The mean age of the physicians who completed the questionnaire was 41 years. The majority were between the ages of 30 and 49 years (68%) with an equal number of men and women. Seventy percent were family physicians, 28.7% internists and less than 2% were community physicians and geriatricians. Physician concerns regarding opioid therapy included prescription drug abuse (84.2%), addiction (74.9%), adverse effects (68%), tolerance (60.7%), and medication interaction (32%). The survey found that the majority of the physicians were comfortable in prescribing narcotics to patients with terminal cancer. However, they were less comfortable prescribing narcotics to patients with low back pain and persons with a current or past history of drug or alcohol abuse. Physician management practices suggested that urine toxicology tests were underutilized with only 6.9% reporting obtaining this test before prescribing opioids and only 15.0% performing urine toxicology tests on patients already prescribed opioids. Logistic regression analysis revealed that whether or not physicians routinely conducted urine toxicology screens was significantly (p = 0.015) predicted by whether they had a system to track patients on opioids when prescribing narcotics. The primary limitation of the study is the reliance on physician self-report rather than objective measures of physician behavior. Conclusions-The survey suggests physicians are concerned about drug abuse, addiction, adverse effects, tolerance, and medication interaction. Their comfort level in prescribing opioids varies with the patient characteristics. Urine toxicology testing is underutilized in the primary care setting.

Low Use of Opioid Risk Reduction Strategies in Primary Care Even for High Risk Patients with Chronic Pain

“…Although patients at increased risk of opioid misuse were more likely to have had urine drug testing, it was still infrequent, with less than one-quarter of the patients with three or more risk factors having any urine drug test. In addition, patients at increased risk of opioid misuse were more likely to receive more than one early refill, but their office-based 24,[30][31][32][33][34] In two primary care studies, only 2 to 18% of patients received urine drug testing. 24,30 We found a similar overall low rate (8%) of urine drug testing but, despite a three to sixfold increase in the adjusted odds of urine testing for patients with multiple risk factors for misuse, only a minority were tested.…”

Risk Factors in Opioid Treatment of Chronic Non-Cancer Pain: A Multidisciplinary Assessment

“…But some data lead one to believe that the overestimation of the risk of addiction is a significant problem (Dews & Mekhail, 2004); in this respect, the term opiophobia has been coined, to refer to the practice of under-prescription of opioid medication due to the fear of inducing addiction in patients (Collett, 1998). By interviewing over 248 US physicians, Bhamb et al (2006) recently reported that just over half of those interviewed (55.9%), had specific clinical protocols for the prolonged use of opioids in patients with chronic non-cancer pain. 35.1% believed they prescribed opioids less frequently than their colleagues; while the most frequent concerns about starting treatment with opioids were the fear of abuse (84.2%) and addiction (74.9%).…”

Safe Opioid Prescribing: A Long Way to Go

“…Physicians' attitudes toward opioid prescribing vary widely, ranging from no prescribing at all to very liberal prescribing. 20,21 There are geographic variations in both prescribing and abuse of prescription opioid analgesics. 22,23 Thus, the increasing prevalence of misuse of and addiction to prescription opioid analgesics attributable to physician prescription appears to be the result of a perfect storm: inconsistent and inadequate physician education, lack of sufficient evidence of efficacy and safety of opioid analgesia for chronic pain, and lack of adherence to guideline-based risk assessment and monitoring.…”