Association of clinical competence, specialty and physician country of origin with opioid prescribing for chronic pain: a cohort study

BackgroundAlthough little is known about why opioid prescribing practices differ between physicians, clinical competence, specialty training and country of origin may play a role. We hypothesised that physicians with stronger clinical competence and communication skills are less likely to prescribe opioids and prescribe lower doses, as do medical specialists and physicians from Asia.MethodsOpioid prescribing practices were examined among international medical graduates (IMGs) licensed to practise in the USA who evaluated Medicare patients for chronic pain problems in 2014–2015. Clinical competence was assessed by the Educational Commission for Foreign Medical Graduates (ECFMG) Clinical Skills Assessment. Physicians in the ECFMG database were linked to the American Medical Association Masterfile. Patients evaluated for chronic pain were obtained by linkage to Medicare outpatient and prescription files. Opioid prescribing was measured within 90 days of evaluation visits. Prescribed dose was measured using morphine milligram equivalents (MMEs). Generalised estimating equation logistic and linear regression estimated the association of clinical competence, specialty, and country of origin with opioid prescribing and dose.Results7373 IMGs evaluated 65 012 patients for chronic pain; 15.2% received an opioid prescription. Increased clinical competence was associated with reduced opioid prescribing, but only among female physicians. For every 10% increase in the clinical competence score, the odds of prescribing an opioid decreased by 16% for female physicians (OR 0.84, 95% CI 0.75 to 0.94) but not male physicians (OR 0.99, 95% CI 0.92 to 1.07). Country of origin was associated with prescribed opioid dose; US and Canadian citizens prescribed higher doses (adjusted MME difference +3.56). Primary care physicians were more likely to prescribe opioids, but surgical and hospital-based specialists prescribed higher doses.ConclusionsClinical competence at entry into US graduate training, physician gender, specialty and country of origin play a role in opioid prescribing practices.

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Opioid analgesic use after ambulatory surgery: a descriptive prospective cohort study of factors associated with quantities prescribed and consumed

BMJ Open ◽

10.1136/bmjopen-2020-047928 ◽

2021 ◽

Vol 11 (8) ◽

pp. e047928

Author(s):

Christopher W Shanahan ◽

Olivia Reding ◽

Inga Holmdahl ◽

Julia Keosaian ◽

Ziming Xuan ◽

...

Keyword(s):

Chronic Pain ◽

High Risk ◽

Drug Use ◽

Opioid Analgesic ◽

Safety Net ◽

Opioid Consumption ◽

Secondary Outcome ◽

Prescribing Practices ◽

Opioid Prescription ◽

Opioid Prescribing

ObjectivesTo prospectively characterise: (1) postoperative opioid analgesic prescribing practices; (2) experience of patients undergoing elective ambulatory surgeries and (3) impact of patient risk for medication misuse on postoperative pain management.DesignLongitudinal survey of patients 7 days before and 7–14 days after surgery.SettingAcademic urban safety-net hospital.Participants181 participants recruited, 18 surgeons, follow-up data from 149 participants (82% retention); 54% women; mean age: 49 years.InterventionsNone.Primary and secondary outcome measuresTotal morphine equivalent dose (MED) prescribed and consumed, percentage of unused opioids.ResultsSurgeons postoperatively prescribed a mean of 242 total MED per patient, equivalent to 32 oxycodone (5 mg) pills. Participants used a mean of 116 MEDs (48%), equivalent to 18 oxycodone (5 mg) pills (~145 mg of oxycodone remaining per patient). A 10-year increase in patient age was associated with 12 (95% CI (−2.05 to –0.35)) total MED fewer prescribed opioids. Each one-point increase in the preoperative Graded Chronic Pain Scale was associated with an 18 (6.84 to 29.60) total MED increase in opioid consumption, and 5% (−0.09% to –0.005%) fewer unused opioids. Prior opioid prescription was associated with a 55 (5.38 to –104.82) total MED increase in opioid consumption, and 19% (−0.35% to –0.02%) fewer unused opioids. High-risk drug use was associated with 9% (−0.19% to 0.002%) fewer unused opioids. Pain severity in previous 3 months, high-risk alcohol, use and prior opioid prescription were not associated with postoperative prescribing practices.ConclusionsParticipants with a preoperative history of chronic pain, prior opioid prescription, and high-risk drug use were more likely to consume higher amounts of opioid medications postoperatively. Additionally, surgeons did not incorporate key patient-level factors (eg, substance use, preoperative pain) into opioid prescribing practices. Opportunities to improve postoperative opioid prescribing include system changes among surgical specialties, and patient education and monitoring.

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Administration of and Prescribing Opioids in Emergency Departments: A Retrospective Study

Kansas Journal of Medicine ◽

10.17161/kjm.vol1413368 ◽

2021 ◽

Vol 14 ◽

pp. 1-4

Author(s):

Casey McNeil ◽

Alma Habib ◽

Hayrettin Okut ◽

Sheryl Beard ◽

Elizabeth Ablah ◽

...

Keyword(s):

Chronic Pain ◽

Drug Overdose ◽

Emergency Departments ◽

The United States ◽

Prescribing Practices ◽

Opioid Prescription ◽

Opioid Medication ◽

Opioid Prescribing ◽

Opioid Administration ◽

Overdose Deaths

Opioid overdose was a cause of 42,249 deaths in the United States in 2016 (13.3 deaths per 100,000) and contributed to 67.8% of all drug overdose deaths in the USA in 2017.1,2 The rate of drug overdose resulting in death in Kansas in 2016 was 11.8 per 100,000, (333 total drug overdose deaths).2 Emergency departments (EDs) are a key intermediary in opioid prescriptions. In 2010, 31% of ED visits nationally resulted in an opioid prescription.3 The number of opioid prescriptions from an ED varies greatly even for a single medical indication. For example, states varied from 40% to 2.8% of patients being prescribed an opioid medication from the ED for ankle sprains among opioid-naive patients treated from 2011 to 2015.4 In Kansas, 35.7% of ankle sprain patients received an opioid prescription from an ED.4 Guidelines for acute pain, including the Alternatives To Opioids protocol (ALTO)5 and the Center for Disease Control and Prevention’s Chronic Pain Guidelines (CDC-CPG)6 are available to guide opioid medication decisions. The ALTO protocol can be used to guide administration and prescription of analgesics for indications that include headache/migraine, musculoskeletal pain, renal colic, abdominal pain, bone fracture, and joint dislocation. The protocol encourages the use of analgesics such as acetaminophen, ibuprofen, and ketorolac prior to opioid administration.5 The CDC-CPG guides the provider into setting goals for pain control, discussing appropriate risks and benefits with the patients, and setting criteria for minimizing long-term opioid use,6 but defers to the American College of Emergency Physician’s 2012 clinical policy guideline for opioid management of chronic pain in the ED. The ACEP recommends against prescribing opioids for acute exacerbation of chronic pain in the ED [Level C recommendation].7 Adopting opioid prescribing guidelines has drastically reduced opioid prescribing rates in some locations.8 For example, a study performed in both a community and an academic medical center tested the implementation of an opioid prescribing guideline that resulted in a decline of opioid prescriptions from 52.7% to 29.8% of patient visits.8 Even in a hospital with less frequent opioid prescribing practices, adopting guidelines has reduced opioid administration in the ED from 22.5% to 17.7%.9 In 2017, 17 states had adopted opioid prescription guidelines10; however, Kansas is not one of those states. Knowing little of opioid prescribing practices in Wichita, Kansas, the purpose of this study was to identify factors that are associated with opioid administration and prescriptions in EDs in Wichita, Kansas, and to evaluate what methods are used by local prescribers to limit opioid administration and prescription in a locality without an opioid prescribing guideline.

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EXPLORINGTHE OPIOID PRESCRIBING PRACTICES OF GENERAL PRACTITIONERS (GPS) IN WEST AND SOUTH ESSEX, UK

International Journal of Advanced Research ◽

10.21474/ijar01/13123 ◽

2021 ◽

Vol 9 (07) ◽

pp. 245-257

Author(s):

Edwin Ugoh ◽

Vincent Icheku

Keyword(s):

Chronic Pain ◽

Pain Management ◽

General Practitioners ◽

Qualitative Data ◽

Prescription Medications ◽

Opioid Use ◽

Prescribing Practices ◽

Nominal Data ◽

Opioid Prescription ◽

Opioid Prescribing

Introduction:The emerging evidence in recent studies shows that Opioid use and abuse have continued to grow at a significant rate, with fatal consequences. The evidence also indicates palpable apprehension and concern over the increasing opiate/ opioid prescription numbers by General Practitioners (GPs). This present study aims to explore the opioid prescribing practices of General Practitioners (GPs) in West and South Essex. The objectives are to answer the following questions: is an opiate prescription based on any available guideline? Is opioid prescribed primarily for pain management? How many times do the GPs prescribe opioids? How long are patients on pain prescription medications? Has the GPs attended training on the use of opioid for pain management? How many years has the GPs spent working as a practitioner? Finally, these researchers believe that answers to these question will add to the knowledge base towards improving the risk-benefit balance of prescribed opiates. Methods:A short self-questionnaire was sent to all GP practices in the South and West of Essex (n=25). There was a response rate of 80 per cent (20/25). Qualitative data from the questions were analysed using thematic analysis. In addition, nominal data were analysed using descriptive statistics to summarise the results. Results:The study found that most of the GPs who participated in the survey are experienced GPs, yet the majority are not complying with prescribing guidelineand thus, overprescribes opioid for pain management. Conclusion:The overprescribing practices of opioids by GPs are affected by an absence of robust guideline on managing chronic pain. Thus, we recommendcompliance with existing guideline and consultation on managing chronic pain over 16s to producea guideline on adult pain management.

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Opioid crisis in primary care? An audit of high-dose opioid prescribing at Bangholm GP Practice

British Journal of General Practice ◽

10.3399/bjgp20x711581 ◽

2020 ◽

Vol 70 (suppl 1) ◽

pp. bjgp20X711581

Author(s):

Charlotte Greene ◽

Alice Pearson

Keyword(s):

Chronic Pain ◽

Back Pain ◽

Practice Guidelines ◽

Best Practice ◽

Evidence Base ◽

High Dose ◽

Opioid Prescription ◽

Opioid Prescribing ◽

Best Practice Guidelines

BackgroundOpioids are effective analgesics for acute and palliative pain, but there is no evidence base for long-term pain relief. They also carry considerable risks such as overdose and dependence. Despite this, they are increasingly prescribed for chronic pain. In the UK, opioid prescribing more than doubled between 1998 and 2018.AimAn audit at Bangholm GP Practice to understand the scale of high-strength opioid prescribing. The aim of the audit was to find out if indications, length of prescription, discussion, and documentation at initial consultation and review process were consistent with best-practice guidelines.MethodA search on Scottish Therapeutics Utility for patients prescribed an average daily dose of opioid equivalent ≥50 mg morphine between 1 July 2019 and 1 October 2019, excluding methadone, cancer pain, or palliative prescriptions. The Faculty of Pain Medicine’s best-practice guidelines were used.ResultsDemographics: 60 patients (37 females), average age 62, 28% registered with repeat opioid prescription, 38% comorbid depression. Length of prescription: average 6 years, 57% >5 years, 22% >10 years. Opioid: 52% tramadol, 23% on two opioids. Indications: back pain (42%), osteoarthritis (12%), fibromyalgia (10%). Initial consultation: 7% agreed outcomes, 35% follow-up documented. Review: 56% 4-week, 70% past year.ConclusionOpioid prescribing guidelines are not followed. The significant issues are: long-term prescriptions for chronic pain, especially back pain; new patients registering with repeat prescriptions; and no outcomes of treatment agreed, a crucial message is the goal is pain management rather than relief. Changes have been introduced at the practice: a patient information sheet, compulsory 1-month review for new patients on opioids, and in-surgery pain referrals.

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Opioid Prescribing Practices in Chronic Pain Management: Guidelines Do Not Sufficiently Influence Clinical Practice

Journal of Pain ◽

10.1016/j.jpain.2009.03.019 ◽

2009 ◽

Vol 10 (10) ◽

pp. 1051-1057 ◽

Cited By ~ 22

Author(s):

Timothy W. Victor ◽

Nancy A. Alvarez ◽

Errol Gould

Keyword(s):

Chronic Pain ◽

Clinical Practice ◽

Pain Management ◽

Chronic Pain Management ◽

Prescribing Practices ◽

Management Guidelines ◽

Opioid Prescribing

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Current Opioid Prescribing Patterns after Microdirect Laryngoscopy

Annals of Otology Rhinology & Laryngology ◽

10.1177/0003489419877912 ◽

2019 ◽

Vol 129 (2) ◽

pp. 142-148 ◽

Cited By ~ 2

Author(s):

Molly N. Huston ◽

Rouya Kamizi ◽

Tanya K. Meyer ◽

Albert L. Merati ◽

John Paul Giliberto

Keyword(s):

The United States ◽

Opioid Abuse ◽

Prescribing Patterns ◽

Opioid Analgesia ◽

Opioid Use ◽

Prescribing Practices ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Opioid Prescription ◽

Opioid Prescribing

Background: The prevalence of opioid abuse has become epidemic in the United States. Microdirect laryngoscopy (MDL) is a common otolaryngological procedure, yet prescribing practices for opioids following this operation are not well characterized. Objective: To characterize current opioid-prescribing patterns among otolaryngologists performing MDL. Methods: A cross-sectional survey of otolaryngologists at a national laryngology meeting. Results: Fifty-eight of 205 physician registrants (response rate 28%) completed the survey. Fifty-nine percent of respondents were fellowship-trained in laryngology. Respondents performed an average of 13.3 MDLs per month. Thirty-four percent of surgeons prescribe opioids for over two-thirds of their MDLs, while only 7% of surgeons never prescribe opioids. Eighty-eight percent of surgeons prescribed a combination opioid and acetaminophen compound, hydrocodone being the most common opioid component. Many surgeons prescribe non-opioid analgesics as well, with 70% and 84% of surgeons recommending acetaminophen and ibuprofen after MDL respectively. When opioids were prescribed, patient preference, difficult exposure and history of opioid use were the most influential patient factors. Concerns of opioid abuse, the physician role in the opioid crisis, and literature about postoperative non-opioid analgesia were also underlying themes in influencing opioid prescription patterns after MDL. Conclusions: In this study, over 90% of practicing physicians surveyed are prescribing opioids after MDL, though many are also prescribing non-opioid analgesia as well. Further studies should be completed to investigate the needs of patients following MDL in order to allow physicians to selectively and appropriately prescribe opioid analgesia postoperatively.

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What physicians need to implement safer opioid prescribing: A qualitative study

Journal of Opioid Management ◽

10.5055/jom.2019.0538 ◽

2019 ◽

Vol 15 (6) ◽

pp. 479-485

Author(s):

Allison Navis, MD ◽

Mary Catherine George, PhD ◽

Maya Scherer, MPH ◽

Linda Weiss, PhD ◽

Yosuke Chikamoto, PhD ◽

...

Keyword(s):

Chronic Pain ◽

Communication Strategies ◽

Insurance Coverage ◽

Patient Specific ◽

Future Research ◽

Successful Implementation ◽

Prescribing Practices ◽

Open Communication ◽

Opioid Prescribing ◽

Control And Prevention

Introduction: In response to the US opioid epidemic, the Centers for Disease Control and Prevention issued a guideline (CDCG) for prescribing opioids for chronic pain. Successful implementation of the CDCG requires identification of the information, skills, and support physicians need to carry out its recommendations. However, such data are currently lacking.Methods: The authors performed one-on-one interviews with nine practicing physicians regarding their needs and perspectives for successful CDCG implementation, including the perceived barriers, focusing on communication strategies. Interviews were audio recorded, transcribed, and a thematic qualitative analysis was performed.Findings: Three major themes were identified: communication, knowledge, and information technology (IT). Physicians reported that open communication with patients about opioids was difficult and burdensome, but essential; they shared their communication strategies. Knowledge gaps included patient-specific topics (eg, availability of/insurance coverage for non-opioid treatments) and more general areas (eg, opioid dosing/equivalencies, prescribing naloxone). Finally, physicians discussed the importance of innovation in IT, focusing on the electronic medical record for decision support and to allow safer opioid prescribing within the time constraints of clinical practice.Discussion: These qualitative data document practical issues that should be considered in the development of implementation plans for safer opioid prescribing practices. Specifically, healthcare systems may need to provide opioid-relevant communication strategies and training, education on key topics such as naloxone prescribing, resources for referrals to appropriate nonpharmacologic treatments, and innovative IT solutions. Future research is needed to establish that such measures will be effective in producing better outcomes for patients on opioids for chronic pain.

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Survey of physician comfort and attitudes on perioperative opioid prescription in patients with chronic pain

Proceedings of Singapore Healthcare ◽

10.1177/20101058211008197 ◽

2021 ◽

pp. 201010582110081

Author(s):

Pei Yu Tan ◽

Diana Xin Hui Chan ◽

Denise Desiree Bi Si Quah

Keyword(s):

Chronic Pain ◽

Pain Management ◽

Online Survey ◽

Prescribing Practices ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Opioid Prescription ◽

Singapore General Hospital ◽

Chronic Pain Patients ◽

Pain Patients

Objective: This study examines current practices, experiences, beliefs, concerns regarding negative outcomes and confidence of non-pain specialty anaesthetists regarding prescribing opioids to chronic pain patients. Design: An electronic cross-sectional survey was conducted by physicians from the Division of Anaesthesiology, excluding pain specialists, at the Singapore General Hospital. Methods: An online survey was conducted, investigating: (a) sociodemographic and practice characteristics; (b) current opioid prescribing practices; (c) experiences and beliefs towards prescribing opioid analgesics for chronic non-malignant pain; (d) confidence and comfort when prescribing opioids; and (e) educational and training needs in chronic pain management. Results: A total of 123 anaesthetists (80.9%) responded to the survey. It was noted that only 38.2% of respondents were comfortable managing patients with chronic pain. The majority (86.2%) felt that anaesthetists should be the primary doctors in the management of postoperative pain in chronic pain patients, and 61% believed that chronic pain trained specialist anaesthetists should be responsible; 92.7% of respondents agreed that patients who are educated about their pain tend to do better. Most importantly, 96.7% of respondents feel that they will benefit from more education regarding pain management in chronic pain patients. Conclusions: The majority of non-pain specialist anaesthetists recognise the importance of education regarding pain management for non-malignant chronic pain patients. Many feel that they are not confident in managing these patients and will benefit from continuing medical education and self-assessment courses to improve their confidence. These results could be used to enrich current pain management courses.

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Trends in opioid prescribing practices in South Korea, 2009–2019: Are we safe from an opioid epidemic?

PLoS ONE ◽

10.1371/journal.pone.0250972 ◽

2021 ◽

Vol 16 (5) ◽

pp. e0250972

Author(s):

Noo Ree Cho ◽

Young Jin Chang ◽

Dongchul Lee ◽

Ji Ro Kim ◽

Dai Sik Ko ◽

...

Keyword(s):

South Korea ◽

Extended Release ◽

Population Based ◽

Prescription Opioid ◽

Prescribing Practices ◽

Geographic Variations ◽

Cross Sectional ◽

Opioid Prescription ◽

Opioid Prescribing ◽

Long Acting

Opioid prescribing data can guide regulation policy by informing trends and types of opioids prescribed and geographic variations. In South Korea, the nationwide data on prescribing opioids remain unclear. We aimed to evaluate an 11-year trend of opioid prescription in South Korea, both nationally and by administrative districts. A population-based cross-sectional analysis of opioid prescriptions dispensed nationwide in outpatient departments between January 1, 2009, and December 31, 2019, was conducted for this study. Data were obtained from the Health Insurance Review & Assessment Service. The types of opioids prescribed were categorized into total, strong, and extended-release and long-acting formulation. Trends in the prescription rate per 1000 persons were examined over time nationally and across administrative districts. There are significant increasing trends for total, strong, and extended-release and long-acting opioid prescriptions (rate per 1000 persons in 2009 and 2019: total opioids, 347.5 and 531.3; strong opioids, 0.6 and 15.2; extended-release and long-acting opioids, 6.8 and 82.0). The pattern of dispensing opioids increased from 2009 to 2013 and slowed down from 2013 to 2019. The rate of opioid prescriptions issued between administrative districts nearly doubled for all types of opioids. Prescription opioid dispensing increased substantially over the study period. The increase in the prescription of total opioids was largely attributed to an increase in the prescription of weak opioids. However, the increase in prescriptions of extended-release and long-acting opioids could be a future concern. These data may inform government organizations to create regulations and interventions for prescribing opioids.

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