Survey of Opioid Prescribing Raises Interesting Questions
As most clinicians know, chronic pain is a major problem in the United States. For many primary care physicians, opioids are an important way to treat it. Yet as opioid prescriptions almost doubled in the last decade,1 a new light has been cast on the rise in drug misuse, abuse, addiction, overdose, and death.2
With so much critical focus being put on "the opioid epidemic," an important question may be overlooked—how do clinicians feel about these drugs now?
"Conflicted" could be an accurate answer.
A recent JAMA survey of primary care physicians found that most understood the dangers of opioid treatments, expressed concern for adverse outcomes, and even recognized that prescription drug abuse was a problem in the communities where they practiced. Yet none of this seemed to affect their own confidence in their clinical abilities.3
Of the 1,000 health care providers surveyed, there was a 58% adjusted response rate. A majority (90%) of the physicians reported prescription drug abuse to be a "moderate" or "big" problem in the community where they work, and 85% believed opioids to be overused in clinical practice. Interestingly, 88% still expressed confidence in their clinical skills, while at the same time, only half (49%) of the physicians felt "very" or "moderately" comfortable prescribing opioid medications to treat chronic noncancer pain (CNCP).
"It is an interesting juxtaposition" said study coauthor G. Caleb Alexander, MD, MS, the co-director for the Center for Drug Safety and Effectiveness. What they discovered reveals a "rapidly changing landscape" in the clinical setting for opioid prescribing, he said, as guidelines evolve right alongside perceptions about the medications involved.
Yet "surveys are an imperfect method to understand individuals," noted Dr. Alexander, and so there could be various reasons why 90% of the practitioners recognized a prescription drug problem in their community and 88% were still wholly confident about their own clinical decisions.
Not My Patients
"To me, this combination of findings suggests that most of the surveyed physicians think that it’s other doctors’ patients who are abusing prescription medications, rather than their own," said Bob Twillman, PhD, FAPM, the executive director for the American Academy of Pain Management.
"I think physicians and other clinicians tend to have strong faith in their own knowledge, skills, and clinical practice, to such an extent that they may overlook evidence of shortcomings in that practice," added Dr. Twillman.
This kind of personal immunity isn't a new phenomenon, at all. Sometimes termed "ego-bias," it's been well-documented over the decades, with numerous studies finding doctors can be frequently influenced by peers, pharmaceutical marketing, and personal expectations.4-6
"Physicians may be over confident that they have clinical skills related to opioid prescriptions. Generally, the majority of the physicians lack these," said Laxmaiah Manchikanti, MD, Chairman of the Board and Chief Executive Officer for the American Society of Interventional Pain Physicians and the Society of Interventional Pain Management Surgery Centers.
Interestingly, only 49% of the clinicians reported feeling “very” or “moderately” comfortable about prescribing opioids for CNCP, regardless of confidence level. Addiction, tolerance, ceiling effects—these doctors reported their own patients having such adverse events, which may be a reason why less than half felt comfortable prescribing opioid treatments for CNCP.
According to Dr. Manchikanti, who's also a medical director at the Pain Management Center of Paducah, in Kentucky, the numbers could be telling of a general lack of guidance for practitioners making decisions in the CNCP setting.
"Very few well trained pain physicians can proceed with these prescriptions. It is not the issue of giving limited prescriptions routinely, limited drugs, or widely numerous drugs, but it is important to determine indications and medical necessity, (and) many physicians lack (that)."
More Education Needed
To Dr. Twillman, the survey also may reveal that practitioners are still learning how to utilize opioids for CNCP, hence the discomfort in prescribing them. In his opinion, vigilance is the strongest policy."In all cases, clinicians need to do a comprehensive evaluation of each individual patient, assessing the potential effectiveness of all available treatment modalities," Dr. Twillman said. "They also always need to do their best to assess the risk that a patient, or someone associated with that patient, will misuse, abuse, or divert their prescription opioids, and to respond appropriately, in terms of how and what they prescribe and how they educate the patient."
As doctors' feelings about how to use opioids for CNCP evolve, policy makers are also taking notice of the opioid epidemic's toll. Today, every state except Missouri has its own Prescription Drug Monitoring Program, according to the National Association of State Controlled Substances Authorities. And as new drugs enter the market, experts agree that using reliable evidence and cautious oversight are essential to ensure the safety of patients.
In March, 2014, a controversial approval by the FDA led to the release of Zohydro ER, the first pure hydrocodone drug without abuse-deterrant properties. In late January, 2015, the company released a reformulated version of Zohydro that includes abuse-deterrant technology, called BeadTek.
"I suspect that we have already reached the point where any new controlled substances that are introduced to the market will have abuse-deterrent properties," Dr. Twillman said. "Of course, as we gain more experience with the products currently on the market, we will have a better idea about how best to use them to maximize patient safety, a process that will need to be repeated as each new technology enters the market."