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Survey: Many Doctors Confused About Opioid Abuse

August 17, 2015
A new survey found that many physicians misunderstand basic facts about opioid abuse, but are in favor of regulation to control prescription drug abuse despite believing that such measures could hamper proper pain management for their patients.

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.”

Positive Findings

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%).

Nearly 9 out of 10 physicians (88%) said they “strongly supported” requiring patients to get opioids from a single prescriber and/or pharmacy, something that would cut down on the number of patients who go from doctor to doctor to get more pain pills than one doctor would prescribe. And 77% believed pharmaceutical companies should be prohibited from marketing opioids for moderate pain.

However, Dr. McCarberg said he found those numbers “suspicious,” given the fact doctors didn’t report how often they used such regulations or how often they prescribed opioid drugs. Also, some doctors could have answered positively so their practice wouldn’t look inadequate, despite the anonymity of the survey, he said.

Dr. Alexander saw the results with some skepticism, too, saying they were “almost too good to be true.”

Perhaps—or perhaps not. Robert Wergin, MD, FAAFP, president of the American Academy of Family Physicians, said he’s found many family physicians actively treating chronic pain and making full use of pain contracts and registries.

Dr. Wergin, himself currently practices out of Milford, Nebraska, and said the patient contracts have been useful to him. Granted, some people suggest patient contracts and drug testing can introduce an adversarial element to the doctor-patient relationship. But to Dr. Wergin, a patient contract simply sets the rules of the prescription from the outset, protecting the doctor and patient, alike.

The patient contract “means we’re on the same page…if the patient violates that contract, it spells out the doctors options. I like that word honesty—it defines the expectations we have in an honest way.”

Patient contracts, urine drug-testing, prescription registries—these are widely endorsed practices.6-8 But they lack evidence-based proof of their efficacy, noted Dr. Alexander, and there could be doctors who find the regulatory measures more of a burden than other doctors.

“There can be destructions to workflow that are an important impediment to implementation; some of the clinical interventions that we examined can be cumbersome if they’re not implemented carefully,” Dr. Alexander said.

“So I would view these findings as an upper limit for clinician support, but I think they nevertheless are reassuring and hold promise that, overall, clinicians recognize the extant of the epidemic and are generally supportive of a variety of clinical and regulatory interventions to try to reduce opioid-related injuries and deaths.”

Prescription drug abuse is the nation’s fastest growing drug problem, according to a report released by the White House in 2011. According to the Centers for Disease Control and Prevention, prescription drug overdose death rates in the United States have more than tripled since 1990 and have never been higher. The clinical use of prescription opioids nearly doubled between 2000 and 2010. By 2009, prescription drugs surpassed motor vehicle crashes as a leading cause of unintentional death, with more people dying from prescription opioids than cocaine and heroin combined.

Funding: The study was supported by the Robert Wood Johnson Foundation Public Health Law Research Program and the Lipitz Public Health Policy Award from the Johns Hopkins Bloomberg School of Public Health. The funding sources played no part in the design, conduct, or analysis of the study and had no influence on the preparation or final approval of the manuscript prior to publication.

Disclosure: Dr. Alexander is Chair of the FDA’s Peripheral and Central Nervous System Advisory Committee, serves as a paid consultant to IMS Health, and serves on an IMS Health scientific advisory board. Johns Hopkins University has reviewed and approved these affiliations in accordance with its conflict of interest policies. Catherine S. Hwang, MSPH, is a current ORISE Fellow at the FDA. Stefan P. Kruszewski, MD, has served as a general and case-specific expert for multiple plaintiff litigations involving OxyContin, Neurontin, and Zyprexa and has had false claims settled as coplaintiff with the United States against Southwood Psychiatric Hospital, Pfizer (Geodon), and AstraZeneca (Seroquel). Andrew Kolodny, MD, is employed by The Phoenix House and is the Director of Physicians for Responsible Opioid Prescribing. Lydia W. Turner, MHS, had no competing interests to declare.

 

Last updated on: October 10, 2016

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