Opioids for Chronic Nonmalignant Pain

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Original Research

Opioids for Chronic Nonmalignant Pain

J Fam Pract. 2001 February;50(2):145-151

References

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We found that physicians who saw more patients were less likely to use more potent opioids. In California, schedule II opioids must be prescribed using triplicate forms purchased from the state. Physicians with high-volume practices may be less inclined to prescribe high-potency opioids because of the time required to complete triplicate forms. Other possible explanations are that these physicians have had more adverse experiences with the use of opioids for CNMP or that they feel more vulnerable to regulatory scrutiny because of their increased volume of patients who might receive opioid prescriptions.

We found that most physicians did not enjoy working with chronic pain patients, and this lack of enjoyment with treating CNMP was a significant barrier to willingness to prescribe opioids in 2 of our 3 models. More investigation of why most physicians do not enjoy working with these patients could further illuminate barriers to the use of opioids for CNMP.

Limitations

There are several limitations to our study. First, the physicians surveyed may not be representative of all practicing primary care physicians. However, CRN physicians are quite similar in many characteristics to family physicians practicing in California.²⁷ Barriers to prescribing opioids in California may also be different from barriers faced by physicians in other parts of the country, so our results may not be easily generalized to other geographic regions. In addition, the data were generated by self-report, and actual practices may differ.

However, our findings are consistent with a 1991 survey of 90 Wisconsin physicians that concluded that concerns about addiction outweigh concerns about regulatory scrutiny for most physicians.²⁸ A national survey of 1912 physicians from multiple specialties found, as we did, a high level of intercorrelation among physician concerns about physical dependence, tolerance, and addiction.²⁹ Unfortunately, that study was not designed to elucidate the relative importance of factors that determine a physician’s willingness to prescribe opioids.

Another limitation of our study is that none of the models we postulated could explain more than a small proportion (24%) of the total variance in the willingness to prescribe opioids for CNMP. Clearly other factors, unmeasured in the current study, also influence physicians’ willingness to prescribe opioids for CNMP. For example, in a study of the prescribing habits at a referral center in Seattle, pain specialists were significantly influenced in their willingness to prescribe opioids for CNMP by a set of pain behaviors exhibited by the patient.³⁰ These behaviors included distorted ambulation or posture, negative affect, facial and audible expressions of distress, and avoidance of activity. The nature of our study did not allow for such factors in our models of willingness to prescribe opioids, but these factors may be worthy of further investigation in direct observation studies of primary care.

Conclusions

Our results suggest that primary care physicians disagree about the relative risks and benefits of opioids in the treatment of individuals who suffer from CNMP. Also, these physicians function with limited reliable information or specialty resources to guide them in choosing which of these patients to treat with opioids. Concerns about addiction, tolerance, and physical dependence appear to be important barriers to the use of opioids by many physicians. More research is needed in primary care settings to determine appropriate uses for opioids in the treatment of CNMP and to further elucidate the concerns of physicians and barriers to more effective use.

Acknowledgments

This research was partially supported by grant #5D32PE19036-09 from the Department of Health and Human Services Health Resources Services Administration to support the establishment of a Department of Family Practice and by a grant from the California Academy of Family Physicians. We would like to acknowledge Dr Eric Sanford, Dr Lawrence Bruguera, Dr Charles Kano, Dr Joyce Hightower, and Dr Yeva Johnson for their assistance with data interpretation and preparation of this manuscript. In addition, we would like to acknowledge the work of Ms Catherine Brosnan and Ms Elizabeth Dito in assisting us with coordination and data collection for our study.

Related resources

American Pain Society http://www.ampainsoc.org/
American Academy of Pain Management http://www.aapainmanage.org
American Pain Foundation http://www.painfoundation.org