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Survey Finds Physicians May View Opioid-Addicted Patients Negatively

Many clinicians have negative attitudes about opioid addiction, often blaming the patient. This, combined with a lack of awareness of effective treatment options, often leave these patients underserved.

Interview with Alene Kennedy-Hendricks, PhD

Many of the physicians on the front line of the opioid prescription epidemic have negative personal feelings about people who develop opioid use disorder (OUD), according to a national web-based survey of primary care physicians (PCPs).1

In fact, most physicians answering the survey attributed responsibility for the development of a OUD solely to the patient. In addition, a large portion of doctors were wholly unaware that treatment options existed for patients with OUD.

“This is really concerning because PCPs are in a position to detect an opioid use disorder and refer individuals to treatment, and stigma towards patients who have substance-related problems may be a barrier to improving access to, and facilitating connections with, substance abuse treatment [facilities],” Alene Kennedy-Hendricks, PhD, lead author of the study and an assistant professor at Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, told Practical Pain Management.

Most physicians support legislative measures to curb opioid abuse, but social stigma about addiction is still prevalent among physicians. Dr. Kennedy-Hendricks and her colleagues conducted the national web-based survey in 2014, prior to the release of new national guidelines. The survey assessed attitudes and beliefs on important topics related to prescription opioid abuse, including PCPs' perceptions of the seriousness of the problem, its causes, groups responsible for addressing it, attitudes toward individuals with prescription OUD, beliefs about the effectiveness of addiction treatments, and support for various policies.

“With many of these questions, we derived them from other social science research on stigma,” she said. The Johns Hopkins researchers had previously researched stigmatized health conditions, including psychiatric disorders like depression and schizophrenia.

Additional questions were based on the 7-point Likert scale, asking doctors to report whether they thought opioids were an effective treatment for managing noncancer acute or chronic pain conditions or asking them to describe their comfort screening patients for substance use and mental disorders.

Addiction Stigma: Does it Affect Treatment Decisions?

The 1,010 respondents to the survey were split among 3 specialties:

  • Family practice (35%)
  • Internal medicine (32%)
  • Pediatrics (33%)

While most physicians (85%) thought opioids were effective for treating acute noncancer-related pain, only 56% thought opioids were an effective treatment option for chronic noncancer pain conditions. The Centers for Disease Control and Prevention (CDC) has recently issued recommendations about opioid prescribing for primary care clinicians treating adult patients with chronic noncancer pain.  “Future research should assess whether attitudes among PCPs regarding opioid prescribing have changed following the release of these guidelines,” the researchers noted.

While a strong majority (72%) of physicians in the survey felt prescription OUD was a “very” or “extremely serious” problem in the US, they still often ranked it below other chronic illnesses, notably obesity, heart disease, smoking, and tobacco use. If a patient did become addicted to the opioids they were taking, 89% of the physicians attributed responsibility solely to the individual. While the second largest proportion of doctors (83%) believed the physician was also responsible for addressing the problem, the difference was statistically significant (P<0.01), the researchers noted.

Most physicians expressed negative feelings about patients with OUD—for example, they were unwilling to have a person with OUD marry into the family (79%) or work closely alongside in the workplace (77%). More than half (66%) thought people with OUD were more dangerous than the general population. Such numbers are concerning, in light of the fact that many surveyed doctors did not believe people with OUD could get better with treatment (31%) or that there were any effective treatment options for OUD even available (58%), noted the researchers.

According to researchers, whether the lack of support for medication assisted treatment (MAT) for OUD is the result of skepticism or simple unawareness could be a hard explanation to pinpoint. “Maybe it’s just a combination of the two, but I think there is a lot of misunderstanding about the effectiveness of medication assisted treatments, like methadone and buprenorphine, and that is the reason we are not seeing higher proportions for that measure,” Dr. Kennedy-Hendricks told Practical Pain Management.

Indeed, while 62% of doctors were comfortable screening patients for substance use disorders, only 13% reported any experience prescribing medication for opioid addiction.

Theory and Practice: High Prescribers May Support Less Reform Policies

Interestingly, professional opinions may have differed according to how often a doctor prescribed opioids. The doctors, triaged as low-volume (prescribed opioids 20 times or less in a typical month) or high-volume prescribers (prescribed opioids more than 20 times in a typical month), had differing opinions about the causes of OUD and the validity of various prescription drug reform policies.  

For instance, low volume prescribers more often felt it was too easy for patients to obtain multiple prescriptions from various doctors (87% vs. 77%; P< 0.01) – referred to as “doctor shopping” – or that patients were kept on opioids for too long (75% vs. 68%; P= 0.04).

On the other side, high-volume prescribers showed somewhat lower support for certain reform policies, particularly the ones targeting physician practice, such as integrating prescription drug monitoring programs into current electronic health records, requiring a physical exam before prescribing opioids, and increasing oversight on clinics where doctors write a large amount of opioid prescriptions.

“This doesn’t seem very surprising to me, but it does suggest that there is some heterogeneity among physicians in terms of their use of opioid prescriptions with patients and how they feel about some of these approaches that may intervene on physicians prescribing of opioid medications,” said Dr. Kennedy-Hendricks. “They may feel that they already know what they’re doing with opioid medications, so they are less receptive to policies that affect what they are already doing.”

Because of this, higher-volume prescribers may be “less amenable” to change their prescribing practices, and while they may agree the opioid abuse is a major public health issue, they still could see physician-related causes as a less significant problem to the opioid abuse epidemic, the authors noted.

However, in a more positive light, the majority of doctors at large supported most reform policies, and while the survey may have been hampered by a low completion rate (29%) typical to physician surveys, most respondents showed a definable trend towards negative stigma related to OUD, something that could be reduced through effective strategies.2

“Future studies should evaluate the effectiveness of communication strategies designed to alter opioid prescribing practices, reduce provider stigma, and increase support for promising policy interventions to address prescription OUD. Research is also needed to assess how physician advocacy maybe leveraged more effectively to advance evidence-based policy interventions,” the authors concluded.

Dr. Kennedy-Hendricks and her colleagues also recently looked at opioid sharing, storage, and disposal practices of US adults, a report that can be found online through JAMA Internal Medicine. Dr. Kennedy-Hendricks said she plans to next analyze subsets of the data based on households containing children. Promoting safe disposal of potent opioid medications like fentanyl has become a major topic of concern in light of the sharp rise in accidental overdose deaths.

This study was supported by a grant from the National Institute for Drug Abuse (NIDA R01 DA026414) and an unrestricted research grant from AIG, Inc. (114061). The funders had no role in the study design, analysis, interpretation, or preparation of this manuscript. Dr. David A. Fiellin has received honoraria from Pinney Associates for serving on an external advisory board monitoring the diversion and abuse of buprenorphine. The other authors of the study had no conflicts of interest to declare.

Last updated on: June 25, 2020
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