Survey: Many Doctors Confused About Opioid Abuse
Reviewed by Forest Tennant, MD, DrPH
As more attention focuses on the US’s opioid epidemic, many clinicians agree that opioid abuse and addiction are serious issues, even in their own communities. However, many of these same clinicians may not fully understand the risks and benefits of the opioids they’re prescribing.
In a recent survey published by The Clinical Journal of Pain, nearly one-half of physicians (46%) erroneously believed that abuse-deterrent formulations made some drugs less addictive than others.1 One-third of the doctors also believed opioids are abused through snorting or injecting, when in reality, opioids are much more likely to be abused in pill form.
“Physicians and patients may mistakenly view these medicines as safe in one form and dangerous in another, but these products are addictive no matter how you take them,” said lead author G. Caleb Alexander, MD, MS, an associate professor in the Department of Epidemiology, at Johns Hopkins Bloomberg School School of Public Health, and co-director of the school’s Center for Drug Safety and Effectiveness, in Baltimore, Maryland.
Surprising findings from the survey included:
- 53% of respondents reported that opioid abuse, misuse and diversion were a “big problem.”
- However, only 25% of respondents were not at all or just slightly concerned about diversion of prescription opioids in their own practice.
- 34% of responders believed illicit opioid use occurs through snorting or injection, when the correct answer is through oral administration.
- Only 13% of the study respondents knew that relatives and friends were the most common source for obtaining prescription opioids for non-medical use.
Abuse Deterrent vs Tamper Deterrent
Opioids that contain abuse-deterrent formulations (ADFs) make them harder to be crushed into a powder or melted into a liquid, which deters people from being able to snort or inject the drug. However, ADFs don’t make opioids any less addictive, noted a number of experts interviewed for this story.
"There’s reason for concern that doctors may misinterpret the label claims associated with abuse deterrents and overestimate the safety of these products,” said Dr. Alexander in an interview with Practical Pain Management.
“The terminology we’re using is all wrong,” said Bob Twillman, PhD, the Executive Director for the American Academy of Pain Management. “What do we expect them to think? In fact what [drugs with ADFs] are is ‘tamper-deterrent,’ not ‘abuse-deterrent.’ The FDA has got us in a little bit of a box with that.”
In April, the US Food and Drug Administration (FDA) released a guidance document outlining how drug manufacturers could establish abuse-deterrence in their drugs.2 FDA sanctioned studies can present evidence in the form of numeric scale ratings measuring “whether the subject would take the study drug again,”3—this language could mislead practitioners into thinking the drugs are therefore less addictive.
Also, primary care providers treat multiple health concerns in addition to pain management, so understanding the distinction between abuse-deterrent and generic formulations may not be a top priority, especially if they don’t regularly prescribe those drugs in the first place, said Bill McCarberg, MD, President of the American Academy of Pain Medicine.
“I think that’s something we’ve been worried about and this survey just shows that at this point from the launch of several of these drugs, there is a misperception about it,” Dr. McCarberg said. The next concern is that that misperception could lead to laxer surveillance of opioid use, putting patients at greater risk of overdose or unchecked addiction.
“There’s no question marketing is a powerful driver of prescribing, that marketing is influential,” said Dr. Alexander. Indeed studies of opioids like the oxycodone (OxyContin), which introduced a tamper resistant formulation in 2012, have been shown to decrease the rates of misuse/abuse-related fatalities.4 A 2015 study also found that the rate of prescription opioid diversion and abuse stabilized or decreased between 2011 and 2013, after increasing between 2002 and 2010.5 The rates of heroin abuse and overdose, however, increased between 2011 and 2013, suggesting that patients may have switched from abusing prescription opioids to abusing heroin.
Misuse Not Well Understood
Dr. Alexander and his team sent out a mail-in survey to 1,000 primary care physicians working in family medicine, general medicine, and internal medicine between February and May 2014. The survey asked practitioners a variety of questions about opioid prescribing. They focused not only on opioid abuse and diversion (the use of prescription drugs for recreational purposes), but also their support for clinical and regulatory interventions that may reduce opioid-related injuries and deaths. Because only 420 physicians completed the survey, the researchers had to account for non-response bias and derived an adjusted response rate of 58%.
The survey found that 34% of responders believed illicit opioid use happens through snorting or injection, when the most common route of abuse actually is swallowing the pills whole. However, it isn’t surprising some practitioners assume opioid drug abuse happens through snorting or injection, said Dr. Alexander.
Snorting and injecting drugs are more associated with illicit use and “so far as [doctors are] thinking about heroin and their model is similar to that of heroin, then one shouldn’t be surprised that a substantial minority, believe that the most common route of abuse is other than swallowing them whole,” Dr. Alexander told Practical Pain Management.
Also, just 13% of the study respondents knew that relatives and friends were the most common source for obtaining prescription opioids for non-medical use, while 25% reported they were not at all or just slightly concerned about the drugs’ potential for diverted use. Interestingly, every physician that took the survey believed prescription drug abuse was a problem in their communities, with 53% reporting it was a “big problem.”
The survey reported some more positive findings, as well. Not only were doctors aware of a prescription drug abuse problem in the communities they practiced, they were overwhelmingly supportive of clinical and regulatory interventions for preventing prescription opioid abuse, like patient contracts (98%) and urine drug testing (90%).