Doctors Prescribing Fewer Opioids for Pain

Doctors Prescribing Fewer Opioids for Pain

Nearly half of primary care physicians in the U.S. say they are less likely to prescribe opioid painkillers than they were a year ago, according to the results of a new survey that also found that most doctors believe their patients “embellish or fabricate” their pain symptoms in order to obtain opioids.

The survey of over 500 general practitioners, family physicians and internists was conducted by the Johns Hopkins Bloomberg School of Public Health. The findings are significant because primary care physicians treat over half of the chronic pain patients in the U.S. and prescribe most of the pain medication. The survey findings are reported in a research letter published in JAMA Internal Medicine.

“Our findings suggest that primary care providers have become aware of the scope of the prescription opioid crisis and are responding in ways that are important, including reducing their overreliance on these medicines,” said study leader G. Caleb Alexander, MD, an associate professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health and co-director of Johns Hopkins’ Center for Drug Safety & Effectiveness.

“The health care community has long been part of the problem and now they appear to be part of the solution to this complex epidemic,” said Alexander, a longtime critic of opioid prescribing practices who advocates the greater use of non-narcotic pain relievers, physical therapy, massage and acupuncture.

The clinical use of prescription opioids nearly doubled in the U.S. between 2000 and 2010, according to the Centers for Disease Control and Prevention. In 2010, over 16,000 Americans died from painkiller overdoses, although most of those deaths involved other drugs or alcohol. Critics have questioned the validity of the overdose numbers and point to federal studies that show only 5 percent of chronic pain patients become addicted to opioids.

bigstock-Doctor-writing-patient-notes-o-16554509Nevertheless, the national furor over the prescription drug abuse “epidemic” has had a chilling effect on doctors, pharmacists and other health care providers – who are turning away from the routine prescribing of opioids to relieve pain.

“Primary care physicians appear to recognize many elements of the prescription drug abuse epidemic, such as the high prevalence of adverse outcomes associated with opioid use,” said Alexander.

“Our investigation suggests that most primary care physicians are aware of many risks of opioids, and many have decreased their prescribing of these products during the past 12 months.”

The risks associated with opioids are not limited to patients. Many doctors are also worried about facing legal problems or even losing their medical licenses for prescribing narcotics. About 45% said they were “moderately” or “very” concerned about malpractice claims, prosecution or censure by a state medical board.

“I think it is true that DEA investigations and prosecutions have produced a chilling effect, leading to circumstances in which patients are struggling to find someone to care for them or even to fill their prescriptions,” said Lynn Webster, MD, past president of the American Academy of Pain Medicine, in an email to National Pain Report.

“There is no question that we have a prescription drug problem in America, but most overdose deaths and adverse outcomes occur with people who have problems aside from or in addition to a legitimate pain problem.  Inappropriate use of and harm from prescription drugs are causing people with legitimate pain to suffer needlessly.”

Other findings in the survey:

  • 90% of doctors believe prescription drug abuse is a big or moderate problem in their community.
  • 85% of doctors somewhat agree or strongly agree that opioids are overused to treat pain.
  • 82% of doctors somewhat agree or strongly agree that patients “commonly embellish or fabricate their pain symptoms” to obtain opioids.

“The findings are consistent with what I have been told by providers across the country.  There is a subset of patients who do not do well with opioids.  These patients are non-responders and thus realistically will not obtain relief from opioids. They often display drug seeking behaviors because they are simply trying to get on top of their pain,” said Webster.

“There are also some people who use the drugs for the wrong reasons.  They use them to treat an anxiety problem, depression, post-traumatic stress or other mental health disorders.  Of course there is also a subset of people who want them to get high.”

bigstock-Mature-doctor-working-on-lapto-14508200Almost 9 out of 10 doctors who were surveyed said they were moderately or very confident in their knowledge of opioid prescribing. But while confident in their prescribing skills, the physicians were less comfortable prescribing opioids for patients with chronic non-cancer pain. Thirteen percent said they were “not at all” comfortable and 38% said they were only slightly comfortable prescribing opioids for non-cancer pain.

One of the co-authors of the study is Andrew Kolodny, MD, an addiction treatment specialist and a well-known critic of opioid prescribing practices. Kolodny is chief medical officer at Phoenix House and President of Physicians for Responsible Opioid Prescribing, a group that has lobbied Congress and petitioned the Food and Drug Administration to limit access to opioids.

“I don’t know the other researchers in this project, but know Kolodny and his strong opposition to the use of opioid medicines. While his employment in addictions is noted in the conflict of interest section, there is no indication of just how strong his attitudes are and activities he’s engaged in. How much and to what extent was he involved in the interpretation of the results?” asks Mark Maginn, a pain sufferer, patient advocate and columnist for National Pain Report.

“Further, this is a small study looking into prescribing behavior and attitudes of the responding physicians. We are rarely treated to this kind of research using pain patients as subjects for investigation of how they think and feel about their use of these medicines.”

The Johns Hopkins study was funded by the Robert Wood Johnson Foundation Public Health Law Research Program and the Lipitz Public Health Policy Fund Award from the Johns Hopkins Bloomberg School of Public Health. The research letter states they had no role in the design of the study or the analysis and interpretation of the data.

In addition to Drs. Alexander and Kolodny, the study was co-authored by Catherine S. Hwang,   Stefan P. Kruszewski, and Lydia W. Turner. Hwang is a research fellow at the Food and Drug Administration. Kruszewski has served as an expert in multiple plaintiff litigations involving OxyContin and Neurontin against Pfizer and AstraZeneca. Turner is a research assistant at the Johns Hopkins Bloomberg School of Public Health.

 

Authored by: Pat Anson, Editor

There are 22 comments for this article
  1. Sandy at 4:07 pm

    BL said, “Those that are receivng adequate treatment and aren’t having problems getting their meds are silent now because they don’t believe they will be affected. Once they are, it will be too late.”

    That’s unfair to say. I live in Florida, have been managed moderately well for a little while and try to make it to local meetings with my State and Federal representatives. Local is especially important. They are often the first line of help you need to lobby. Your local State Delegation. We just spoke to ours about MMJ. It didn’t pass our amendment but had so much support and well over 50% the State of Florida is willing to listen and legislate on it.

    I do talk to them. I can’t make every meeting everywhere, who can? There are many more that do more and hurt just as much or more. Others advocate for family members of folks like me. My family helps too.
    It ALL matters.

  2. BL at 2:18 pm

    JeanAnn, it would be better if you had changed drs. The new dr may or may not keep you on the same meds at the same doses you’ve been on. There are other drs.

  3. JeanAnn at 3:18 pm

    My doctor has me so cowed and is very argumentative. He is trying to retire and find a doctor that will take his pain patients. It is now the third month that has passed his retirement plans. He is stuck in a ‘Comprehensive Health Care Network’ group he sold his practice to them. Anyway. He makes me scared of him and you better not try to debate him. Don’t cry because ‘he hates that’, puts him in a fighting mood. I’ve gone to him for 11 years and have been on lots of medicine. I dread seeing him before each appointment. It is sad that this is happening to so many people in pain, and no one know how another feels, and – I wouldn’t wish this on anybody.

  4. LMP at 8:03 pm

    I have been using the same dose of Percocet for over 10 years. I don’t get high, I don’t abuse them. They gave me my life back. End of story.

    Once I realized IC is incurable and treatment is guesswork, I stopped treating the disease and treated the symptoms. Changed everything. Get a pain specialist, and keep your life together!

  5. M w/ fibro & cmps at 9:39 pm

    My primary care physician left her practice and the doctor who took over is fresh out of her residency work. She has no clue about my primary diagnosis that my permanent disability was granted, which is Fibromyalgia & Chronic Myofascial Pain Syndrome. I suffer from several other pain related problems, bipolar disorder, anxiety, and PTSD. Despite a history of long term physical abuse in my teens, 21 surgeries (with at least 3 more in my future), scoliosis, tendonitis, lower back disease, restless leg syndrome, migraines, arthritis, bursitis, hyper mobility, etc., after more than 16 years of the same doses of Valium and oxycodone, she refuses to refill them because she is afraid of jeopardizing her license. It took many years to come up with the drug therapy that has worked best for me. I’ve tried and/or am unable to handle massage, chiropractic, pain injection, biofeedback, and yoga therapy. I now have less than 30 days to find a doctor who will continue prescribing my current medications, all of which are for very clearly documented health problems. I am terrified that my body will suffer from withdrawals, my sleep will worsen, and the effects on my bipolar disorder, which I have taken great pride in treating with a mood stabilizer and psychotherapy. I now have torn miniscus in both knees and damage in my right ankle that needs to be addressed. I have sought help from my insurance company and the presiding hospital. I do not want to “play” with other drugs. I’ve already done that and have had problems with many, ranging from feeling drunk to gambling problems. Living alone and with a limited income from Social Security, I am unable to physically seek out new physicians. My plan is to take care of the current problems with my body so that I can get back on track with a swimming exercise program. I haven’t asked for dosage increases, despite my surgeries and new pain. My case history is well documented and I have the support of my pharmacist regarding my medications. I now face a frightening future because of ignorance, unwillingness to educate themselves on the doctors end, and the flagrant abuse, misuse, and the illegal selling of prescribed medication by a small population of patients. Having no history of drug or alcohol abuse, I am one of millions who are paying the high price of those who have abused the system. I pray that none of this impairs me psychologically or physically to the point where I am unable to have any quality of life, or to a point where I may unintentionally kill myself because of severe pain combined with sleep deprivation. I pray for all of those with chronic pain who are now facing similar situations. By the way, I have begun filing complaints with the hospital, my insurance company, and the state against the new doctor who told me that none of my conditions warrant the use of prescription narcotics. I am so grateful to the DEA for frightening our physicians! Good luck to everyone!

  6. BL at 10:05 am

    Tracy Gum, Well Said ! It is a shame that those being adversly affected can’t or won’t get to at least the same level as those against it, if not above. The squeaking wheel gets the oil saying comes to mind. There are plenty of people speaking out online, but that’s it. And online only will do nothing to change anything. Those that are receivng adequate treatment and aren’t having problems getting their meds are silent now because they don’t believe they will be affected. Once they are, it will be too late.

  7. Tracy Gum at 9:58 pm

    Oh!…. And to REALIST!

    I’m a realist to…… Do you know that you have something like 1 in 5 chance of getting a chronic pain illness in your life? And what’s even better for you is that those odds increase as you get older…lol

    Your chances are not that great, as I am sure, your post has greatly increased your odds. I’m sure there are quite a few reading it that are willing that fact to be completely true for you the Realist!

    I wouldn’t wish what I have on anyone but for YOU I would make an exception.

    Have a nice life.

  8. Tracy Gum at 9:46 pm

    Like most things with this argument the winners will be be the group that can shout the loudest (the most financial incentives behind them) and can instill the most fear in their colleagues …….

    Once these anti pain treatment people make a big enough noise …. It then becomes politicly improper to support the use of certain medications this group says nothing, and all of a sudden the research says prescribing is down and the pain patients are exaggerating???

    It’s got nothing to do with good medical practice or treatment… And all to do with how much money they can save for the government and the general practitioners being bombarded with the fear of malpractice suits…

    The patient with pain completely loses and if the doctors really believe that most of us with pain are exaggerating then God help us all …….

    Means pain management is not only, not going to change, its gotten worse, there is nothing humane about this crap!

  9. Randall Heathcoe at 1:02 am

    People who are on Disabilty with chronic pain should have the wright to get all the pain meds they need until their pain have stoped.Doctors should have the wright to oversee this,without any others consent!
    To suffer is the real EVIL IN THIS WORLD.

  10. BL at 1:34 pm

    Jennifer, I agree. Even the data that is published is misrepresented.

  11. Brenda Alice at 2:48 am

    Please stop the discrimination against people with chronic painful diseases. The DEA needs to focus on the criminals and dealers and leave the disabled alone. The doctors and pharmacies are scared, rightfully so. Tennessee is even investigating the ones that prescribe or fill narcotics and brags about it. I have been disabled 20 years. Not by choice. But to take away the narcotics that allows me to get to the bathroom each day is a shame. I will not live long completely bedfast nor will I live in pain worse than I have.

  12. Jennifer at 4:38 pm

    Well, I think 82% of doctors “commonly embellish or fabricate data on the safety and efficacy of non-narcotic medications” to get patients to shut up.

  13. BL at 4:07 pm

    mark maginn, it is evident that Realist has problems that they aren’t aware of, let alone seeking treatment for. Those who suffer from chronic severe pain, know what their physical problems are that cause that pain.

  14. mark maginn at 1:43 pm

    Well, you may be a realist, but you don’t know what you are talking about. I rather doubt you’ve faced the hellish reality of constant pain that disrupts everything in your life. In addition, I’m always intrigued by people who make such sweeping statements without offering even the shadow of proof. Must work well for you.

    I’ve been too polite. Do you have any notion at all about what your vapid statement might mean to those of us who suffer from harrowing pain? Your ignorant response is one that far too many of us have had to deal with. I don’t intend to educate you as your statement indicates that you are probably not educable. I hope you live long enough to join us.

  15. Realist at 12:05 pm

    “Pain”, just another crutch for underlying psychiatric disease and addiction problems

  16. Dennis Kinch at 5:25 am

    Is anyone else scared? I mean, this is the kind of thing that leads to meds being cut because people read this fear mongering crap and get out the ax.
    “Our findings suggest that primary care providers have become aware of the scope of the prescription opioid crisis and are responding in ways that are important, including reducing their overreliance on these medicines,” see it? ”

    The prescription overdose crisis!” really? You mean the one you all invented? You mean the one 2 politicians who must have owed somebody something started? You mean the same crisis that a state governor made up a law against only to be overturned by the state’s supreme court because “He overreacted. There is no crisis in our state.” (?) The same one that caused millions of perfectly law abiding pain patients to go through a lot of suffering for nothing? That one?

    I’m all in favor of freedom of the press but please, when you print anything like this again, put in a disclaimer that states: there never was proof of an epidemic or crisis. You’re scaring me to death…literally.

  17. Carrie at 5:42 pm

    I think that many people who have been living with intractable chronic pain down play their pain and suffering. We don’t want to be the nail that sticks up. I could Easily be able to be more active if my breakthrough meds were increased. But I am not going to rock the boat.

  18. NOTSONUTSO at 5:22 pm

    I’ve been on percocet almost 15 yrs. Without it I would be in agony. My dr. retires in two years. I guess in two years I will be a goner. So scared.

  19. Kurt W.G. Matthies at 1:59 pm

    The survey offers no surprises for this observer: PCPs have always been conservative in their treatment using opioids.

    Most people do not understand the education of physicians in America. While considered long and arduous by even the best of students, medical training stresses the voluminous scientific facts of human health and disease, but is conspicuous for its absence of practical training in the treatment of sick people. American physicians learn to use their prescription pad not in medical school, but within the clinical setting over time, during the practice of medicine.

    During this practice, many of those doctors who become PCPs learn, as Dr. Webster describes, “there are also some people who use the drugs for the wrong reasons. They use them to treat an anxiety problem, depression, post-traumatic stress or other mental health disorders. Of course there is also a subset of people who want them to get high.”

    I doubt that I’ll ever meet a perfect human being. Sophocles extemporized that the arrogant and self-ignorant who pretend to be without sin find themselves impaled upon the pike of hubris of their own accord. Experience shows that all of us have both positive and negative characteristics that drive our desires. For a small percentage of human-kind, prescription drugs are the object of this desire.

    PCPs, like pharmacists, are the gatekeepers of prescription drugs and tend to err on the side of conservative treatments for most conditions, not just pain.

    What is unfortunate is that during the past five years, medical science is getting mixed messages, conflicting information, and skewed data regarding the treatment of pain. Practitioners are being overwhelmed by data — over 800 reports last year on pain medicine alone, and quite frankly PCPs who must stay current on therapies for all pathologies cannot keep up with the flow of information.

    At the same time, they are being alerted to risks of prescribing controlled substances to their medical license and livelihood, including a barrage of negative messages about opioid prescribing from groups like PROPs.

    In this report, I find myself, perhaps for the first time, in agreement with Andrew Kolodny. I too think that in all this confusion, many PCPs are simply shutting down when it comes to prescribing for opioid analgesics for pain.

    I believe that we are seeing the result of that “chilling effect,” in the these attitudes reported here. On the other side of the equation, many pain patients are complaining of lack of treatment, especially those in the so-called profile group of males ages 18 to 35. My own chronic pain condition due to spine disease first appeared during these years I was fortunate to present during a time of enlightenment in the treatment of pain. Today’s patients do not have the pain treatment options offered to me over 30 years ago.

    Today the shadow of inflated statistics regarding opioid prescription mortality, the inflated importance of a relatively few cases of opioid induced hyperalgesia, and fears over persecution for writing controlled prescriptions are causing a pushback against the standard of care for treating people in pain. As a result, more people suffer.

    The true epidemic is not prescription drug poisoning, but the tens of millions in pain today in America, and the corresponding 1.5 billion in pain throughout the globe.

  20. BL at 1:51 pm

    I wonder how many of these drs either referred their patients to Pain Management Drs or their patients found Pain Management Drs on their own ? This study may or may not be somewhat accurrate when it comes to Primary Care Drs. I do wonder what the increase in patients seeking treatment and being treated by Pain Management Drs is ? When reading this study one has to remember that it only applies to Primary Care Drs.