Chronic pain is one of the most common reasons for seeking medical attention in the United States, and such pain is frequently treated with prescription opioids. The clinical use of these products nearly doubled between 2000 and 2010,1 with simultaneous increases in the incidence of opioid abuse, addiction, injury, and death.2 Because primary care physicians play a critical role in maximizing the safe use of these products, we examined their beliefs and self-reported practices regarding prescription opioid use.
We used the Dillman3 approach to conduct a nationally representative postal mail survey. We sampled 1000 practicing US internists, family physicians, and general practitioners using the American Medical Association Masterfile. Participants were sent a questionnaire, $2 cash incentive, and self-addressed stamped envelope in February 2014, and nonrespondents were contacted a maximum of 3 times in approximately 6-week intervals. Response patterns between early and late responders were similar, suggesting the absence of nonresponse bias. However, because of modest sociodemographic differences between respondents and nonrespondents, we incorporated poststratification weights in our analyses. The questionnaire and study protocol were exempted from review by the institutional review board of the Johns Hopkins Bloomberg School of Public Health. The study did not require informed consent because it did not qualify as human subjects research.
Our adjusted response rate was 58%, and physician characteristics are reported in Table 1. Most physicians (90%) reported prescription drug abuse to be a “big” or “moderate” problem in their communities, and more than four-fifths (85%) reported that opioids are overused in clinical practice (Table 2). A majority of physicians (65%-84%) reported being “very” or “moderately” concerned about each potential adverse patient outcome that was assessed, including opioid-related addiction (55% reporting “very concerned”), deaths (48%), and motor vehicle accidents (44%). Furthermore, most physicians reported high frequencies of adverse events—such as tolerance (62% reported occurring “often”), physical dependence (56%), and ceiling effects (36%)—even when prescription opioids are used as directed to treat chronic pain. Physicians expressed somewhat lower degrees of concern for potential adverse prescriber outcomes associated with opioid prescribing, such as malpractice claims and censure by state medical boards. Approximately one-half of physicians (45%) reported being less likely to prescribe opioids compared to 1 year ago. Despite this, nearly all physicians (88%) expressed confidence in their clinical skills related to opioid prescribing, and nearly one-half (49%) were “very” or “moderately” comfortable using these drugs for chronic noncancer 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.4,5 Although our study did not allow for longitudinal assessment of these physicians’ attitudes or knowledge over time, substantial publicity and raising of awareness on the part of many stakeholders may have contributed to these findings. Physicians’ high levels of confidence in their own prescribing are also of note and may reflect a combination of their experiences, as well as cognitive biases that have been demonstrated in other settings.6,7
Our study has limitations. First, our results are based on self-report and prone to socially desirable response bias. We minimized this potential by ensuring participant confidentiality and avoiding leading questions. Second, nonresponse bias may have influenced our findings. To reduce this impact, we maximized survey participation rates using the Dillman method and implemented poststratification weights in our analyses.
Given the increasing use of opioids in clinical practice and its attendant morbidity and mortality, understanding primary care physicians’ prescribing patterns, as well as their perception of adverse events associated with the use of these products, is crucial. 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.
Corresponding Author: G. Caleb Alexander, MD, MS, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, W6035, Baltimore, MD 21205 (firstname.lastname@example.org).
Published Online: December 8, 2014. doi:10.1001/jamainternmed.2014.6520.
Author Contributions: Ms Hwang and Dr Alexander had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data: Hwang, Turner, Kolodny, Alexander.
Drafting of the manuscript: Hwang, Turner, Kolodny, Alexander.
Critical revision of the manuscript for important intellectual content: Hwang, Kruszewski, Kolodny, Alexander.
Statistical analysis: Hwang, Kolodny.
Obtained funding: Turner, Alexander.
Administrative, technical, or material support: Turner, Kruszewski, Alexander.
Study supervision: Turner, Alexander.
Conflict of Interest Disclosures: Ms Hwang is a current ORISE Fellow at the Food and Drug Administration. Dr Kruszewski 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). Dr Kolodny is employed by the Phoenix House and is President of Physicians for Responsible Opioid Prescribing. Dr Alexander is Chair of the Food and Drug Administration’s Peripheral and Central Nervous System Drugs Advisory Committee, serves as a paid consultant to IMS Health, and serves on an IMS Health scientific advisory board. This arrangement has been reviewed and approved by Johns Hopkins University in accordance with its conflict of interest policies. No other disclosures are reported.
Funding/Support: This work was supported 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.
Role of the Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: Kenneth Rasinski, PhD, Joint Commission, provided helpful input on survey development, fielding, and analysis. He was not compensated for his contribution.
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