Friday, August 9, 2013

Influences on Opioid Rx for Chronic Pain Studied

PrescribingOpioids are still among the most commonly prescribed analgesics for treating moderate-to-severe pain. Overall, their use has been increasing even though prescribers are becoming concerned about adverse effects, misuse and abuse, morbidity and mortality, and scrutiny by federal and state regulatory agencies. Two recently published surveys of healthcare providers show that some have stopped prescribing opioids entirely for chronic noncancer pain while others, having more experience with opioids and positive attitudes, continue to prescribe these essential drugs without reluctance.

Opioid Prescribing Changes in Washington State Surveyed

In the first study, researchers in Washington State conducted a survey of primary care physicians and advanced registered nurse practitioners (ARNPs) in the state to understand changes in practice patterns regarding the prescription of opioids for treating chronic noncancer pain (CNCP) [Franklin et al. 2013]. Data were gathered via a web-based anonymous survey conducted during March-August 2011. Participants included a convenience sample of healthcare providers in Washington representing diverse geographic regions and healthcare organizations.

Writing in the July/August 2013 edition of the Journal of the American Board of Family Medicine the researchers report that 623 of 856 provider respondents (73%) claimed to treat patients with CNCP, and these practitioners served as the analysis sample. Most of these providers (72%) reported concerns about opioid overdose, addiction, dependence, or diversion, while only 25% indicated concern about regulatory scrutiny.

Only a small proportion of providers overall (3.3%) said that they had stopped prescribing opioids for CNCP, but twice as many ARNPs (5.8%) as physicians —MDs or osteopaths — (2.1%) reported opioid discontinuation. At the same time, a greater proportion of physicians (71%) than ARNPs (40%) reported familiarity with the Washington State opioid dosing guidelines then in existence.

Of interest, physicians in a large health plan serving 400,000 members in Washington (Group Health), which has substantial infrastructure support, reported less concern about problems with opioids compared with providers in other settings. For example, no providers with Group Health had stopped prescribing opioids; whereas, of providers in Spokane (the largest city in Eastern Washington), 45% reported very low capacity to access pain specialty consultation or other support and consequently were less frequent prescribers of opioids at any dose.

The vast majority of providers reported a need for more efficient, innovative means of support and education related to treating patients with CNCP. Overall, prescribers in Washington reported ongoing concerns regarding opioid use for CNCP, but those affiliated with a large healthcare organization and having access to pain consultation were less likely to report being concerned about opioid-related problems or to have discontinued prescribing opioids.

Opioid Rx Rates Influenced by Prescribers’ Attitudes & Experience

The second study was industry-sponsored (Janssen Scientific Affairs) and published in the June 2013 edition of the Journal of Pain. Researchers found that practitioners’ attitudes about pain drugs closely affect how often they prescribe opioids for CNCP (chronic noncancer pain) [Wilson et al. 2013]. As might be expected, negative physician attitudes about opioid medications appear to be associated with lower rates of prescribing and more favorable attitudes are linked with higher prescribing levels.

This study, conducted by University of Washington researchers and collaborators, used a 38-item questionnaire to assess present-day attitudes reflecting impediments and concerns regarding opioid prescribing, perceived efficacy of opioids, medical education, and benefits of tamper resistant formulations (TRFs). Of 1,535 physicians assessed in the final survey more than 70% reported using opioids in fewer than 30% of their patients with CNCP.

Of particular interest, those physicians who treated higher volumes of patients experiencing CNCP were more likely to prescribe opioids and said that they were less concerned with impediments surrounding opioids, were not worried about or avoidant of prescribing Schedule II vs. Schedule III drugs, believed in the benefits of TRFs, and thought that they were adequately trained to treat chronic pain.

According to the researchers, these results are consistent with other studies showing that physician uneasiness with prescribing long-term opioids for chronic pain is linked with inexperience in using the medications. There were no differences evident in overall physician attitudes about opioids in various areas of the country; however, the researchers noted that orthopedists expressed the most negative views of opioids, showed the lowest level of confidence in opioid efficacy, and had the highest average levels of concern about opioid addiction, tolerance, and dependence.

COMMENTARY: The survey by Franklin and colleagues [2013] may be conveying false perceptions that are contrary to current realities in Washington State. For one thing, the survey depicts a point in time that may no longer be relevant; that is, data collection was concluded in August 2011, but the study was not even submitted for publication until 14 months later in October 2012 and was just recently published in summer 2013.

Meanwhile, aggressive new laws (as opposed to mere guideline recommendations) for the management of CNCP — intended to curb opioid-related problems in Washington State — had gone into effect in January 2012 [see discussion in UPDATE here]. In advance of enactment of the new rules, some reports noted that as many as 70% of community health clinics in the state had stopped treating patients with chronic pain, and most of those that still did treat such patients would not provide opioid analgesia. Therefore, the out-of-date survey by Franklin et al. may grossly understate the extent to which prescribing practices negatively changed in the state.

Furthermore, the survey by Franklin et al. used a convenience sample, with a low response rate, that was slanted toward physicians in the large and highly supportive Group Health system. These respondents were less intimidated by opioid-dosing guidelines than other prescribers in the state — eg, none in Group Health had completely discontinued opioid prescribing — but this may or may not hold true today, more than 2 years after the survey. Meanwhile, all indications are that problems have grown worse rather than better for patients who might benefit from opioid therapy for chronic pain in Washington State; and, there have been other unintended consequences.

For example, according to newly reported research, heroin use is on the rise in Washington State and the upsurge can be traced to the new laws that made it more difficult to obtain prescriptions for opioid analgesics [see June 12, 2013 U.S. News & World Report article here]. Implementation of the new opioid-Rx laws decreased the numbers of people abusing opioid analgesics, but also increased the demand for heroin in the state.

As noted by study author Caleb Banta-Green of the University of Washington, “We were either progressive or regressive with that aggressive effort to reign in opiate prescribing before a lot of the country.” He conceded, “It shows if you enact these laws, you get some of the intended effects — high school sophomores have significantly decreased the rate at which they’re abusing prescription opiates — but people are also diverted to heroin.” This increase in heroin use is not new, and has been occurring nationwide as regulators and legislators have tried unsuccessfully to grapple with opioid-related problems [see most recent UPDATE on this topic here].

The second study noted above, by Wilson et al. 2013, appears to confirm general assumptions that prescriber attitudes toward opioid prescribing are favorably influenced by their education and experiences in using the drugs and by treating more patients with CNCP. It seems to be a case of familiarity with opioids and their effectiveness builds comfort that overcomes other concerns.

Among the various speciality groups surveyed, orthopedists were most troubled by impediments/concerns relating to long-term opioid use and had the least confidence in opioid efficacy, whereas pain medicine specialists and physical medicine and rehabilitation specialists were the most confident in opioid use and effectiveness. However, it must be considered that orthopedists most often treat patients with acute pain conditions and have less familiarity with CNCP.

The survey revealed additional factors that may influence attitudes and prescribing practices; although, the significance and universal applicability of these should be circumspectly considered. For example, male physicians on average believed more strongly in the efficacy of opioids for CNCP than females; physicians <45 years of age were slightly less confident in prescribing opioids compared with those between 45 and 60 years; and physicians with less than 10% of their patients having chronic pain believed significantly less in opioid efficacy compared with those having greater percentages of patients with CNCP.

Taken together, the two studies appear to emphasize practitioners’ needs for evidence-based guidance, tools and resources, as well as ongoing education regarding benefits and risks of opioid analgesics for CNCP. As might be expected with any medical therapy, practitioner confidence and expertise increase as opioid prescribing experience accumulates. This further suggests that generalizations about successes or failures of opioids for treating CNCP conditions should take into account differential qualifications, attitudes, and beliefs of the prescribing healthcare providers.

REFERENCES:
> Franklin GM, Fulton-Kehoe D, Turner JA, et al. Changes in Opioid Prescribing for Chronic Pain in Washington State. J Am Board Fam Med. 2013;26:394–400 [
access here].
> Wilson HD, Dansie EJ, Kim MS, et al. Clinicians' Attitudes and Beliefs About Opioids Survey (CAOS): Instrument Development and Results of a National Physician Survey. J Pain. 2013(Jun);14(6):613-627 [
abstract].

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