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.
Nevertheless, 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.”
Almost 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.