Primary Care Physicians’ Knowledge And Attitudes Regarding Prescription Opioid Abuse and Diversion

Abuse-Deterrent Opioids: A Survey of Physician Beliefs, Behaviors, and Psychology

Objective

Evaluate beliefs and behaviors pertaining to abuse-deterrent opioids (ADFs).

Design

Survey in 2019 by invitation to all licensed physicians.

Setting

Commonwealth of Kentucky.

Participants

374 physicians.

Methods

Descriptive statistics, and hypothesis test that early adopter prescribers would have greater endorsement of opioid risk management.

Results

Of all prescribers, 55% believed all opioid analgesics should have ADF requirements (15% were unsure); 74% supported mandating insurance coverage. Only one-third considered whether an opioid was ADF when prescribing, motivated by patient family diversion (94%) and societal supply reduction (88%). About half believed ADFs were equally effective in preventing abuse by intact swallowing, injection, chewing, snorting, smoking routes. Only 4% of OxyContin prescribers chose it primarily because of ADF properties. Instead, the most common reason (33%) was being started by another prescriber. A quarter of physicians chose not to prescribe ADFs because of heroin switching potential. Early adopters strongly believed ADFs were effective in reducing abuse (PR 3.2; 95% CI 1.5, 6.6) compared to mainstream physicians. Early-adopter risk-management practices more often included tools increasing agency and measurement: urine drug screens (PR 2.0; 1.3, 3.1), risk screening (PR 1.3; 0.94, 1.9). While nearly all respondents (96%) felt that opioid abuse was a problem in the community, only 57% believed it was a problem among patients in their practice. Attribution theory revealed an externalization of opioid abuse problems that deflected blame from patients on to family members.

Conclusions

The primary motivator for prescribing ADFs was preventing diversion by family members, not patient-level abuse concerns.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40122-021-00343-z.

Are US Plastic Surgery Residents Equipped to Face the Opioid Epidemic? A National Survey

The United States opioid epidemic is among this century’s most profound threats to public health and demands that all physicians consider their role in reversing its trajectory. Previous literature demonstrated that plastic surgery trainees lack vital practices that promote opioid stewardship. However, it is not understood why this practice gap exists. This is a national survey-based study evaluating the availability and effectiveness of opioid education in US plastic surgery programs. A total of 91 residents completed the survey. Our study found that there is an unmet need for practical and comprehensive training regarding safe opioid prescribing among plastic surgery trainees. “Informal training,” defined as the “learn as you go” method, was found to be more common than formal training and considerably more valuable according to trainees. Trainees cited real-world applicability of informal training and that it comes from teachers whom they know and trust as valuable attributes of this type of education. Furthermore, the severity of the opioid epidemic has not translated into improved trainee education, as there was no significant difference in knowledge on safe opioid prescribing practices between junior and senior residents. To change the course of the epidemic, plastic surgery programs need to better train younger generations who believe they are critical stakeholders. This study lays the framework for the “formalization of informal training,” and the creation of practical and efficacious educational initiatives.

Primary care physicians' preparedness to treat opioid use disorder in the United States: A cross-sectional survey

BACKGROUND

Efforts to increase opioid use disorder (OUD) treatment have focused on primary care. We assessed primary care physicians' preparedness to identify and treat individuals with OUD and barriers to increasing buprenorphine prescribing.

METHODS

We conducted a cross-sectional survey from January-August 2020 which assessed perceptions of the opioid epidemic; comfort screening, diagnosing, and treating individuals with OUD with medications; and barriers to obtaining a buprenorphine waiver and prescribing buprenorphine in their practice. Primary care physicians were sampled from the American Medical Association Physician Master File (n = 1000) and contacted up to 3 times, twice by mail and once by e-mail.

RESULTS

Overall, 173 physicians (adjusted response rate 27.3 %) responded. While most were somewhat or very comfortable screening (80.7 %) and diagnosing (79.3 %) OUD, fewer (36.9 %) were somewhat or very comfortable treating OUD with medications. One third of respondents were in a practice where they or a colleague were waivered and 10.7 % of respondents had a buprenorphine waiver. The most commonly cited barriers to both obtaining a waiver and prescribing buprenorphine included lack of access to addiction, behavioral health, or psychiatric co-management, lack of experience treating OUD, preference not to be inundated with requests for buprenorphine, and the buprenorphine training requirement.

CONCLUSIONS

While most primary care physicians reported comfort screening and diagnosing OUD, fewer were comfortable treating OUD with medications such as buprenorphine and even fewer were waivered to do so. Addressing provider self-efficacy and willingness, and identifying effective, coordinated, and comprehensive models of care may increase OUD treatment with buprenorphine.

Evaluation of medical students' knowledge of psychoactive substances in the context of their future role in addiction prevention and therapy

This study assesses the knowledge of medical students on the health effects of the use of psychoactive substances, in the context of their future role in prevention and treatment of addictions. The study was conducted using a questionnaire containing questions about classification, symptoms and effects of psychoactive substances, and the existing prevention programs. The study involved 430 students of medicine and allied faculties. Only 20.8% of medicine students and 12.5% of students of other faculties could correctly classify different psychoactive substances. Correct symptoms of drug misuse were mentioned by 20.4% of medicine students and 19.2% of students of other faculties. The overall knowledge of medical students was no greater than the knowledge of students of other allied faculties. Medical students showed insufficient knowledge about psychoactive substances and their effects on the human body, thus indicating the need to introduce into their study programme a more teaching in this area.

Barriers and Challenges to Making Referrals for Treatment and Services for Opioid Misuse in Family Planning Settings

Background: In this opioid overdose epidemic, women are an overlooked group seeing increasing rates of overdose death. Implementation challenges have prevented evidence-based interventions from effectively reaching women who misuse opioids, with gaps in access to effective treatment and services. Family planning clinics could serve as important points of contact for referral to needed treatments and services. The study explores how family planning staff knowledge and attitudes related to opioid misuse serve as potential barriers and challenges in making referrals for evidence-based services and treatments. Methods: In 2018, we conducted a national online survey of family planning staff, assessing knowledge and attitudes of treatments and services for opioid misuse. Results: A total of 691 family planning staff completed the survey. Most respondents agreed that opioid misuse was a major problem in their community (86.0%) and identified challenges in responding to it, including a lack of treatment access (70.3%), the absence of in-house behavioral health staff (67.2%), and unfamiliarity with local treatment providers (54.1%). Respondents reported low levels of acceptability for syringe services programs (46.0%), medications such as methadone and buprenorphine (55.4%), and naloxone to reverse opioid overdose (60.1%). Controlling for other factors, race/ethnicity, urbanicity, workplace role, and substance use training were associated with differences in acceptability. Conclusions: Family planning settings could play a critical role in connecting women who misuse opioids to treatment and services. Strategies are needed to increase the acceptability of evidence-based interventions and the feasibility of having family planning staff play a linkage role.

Identification and Management of Opioid Use Disorder in Primary Care: an Update

PURPOSE OF REVIEW

The rising prevalence of opioid use disorder (OUD) and related complications in North America coupled with limited numbers of specialists in addiction medicine has led to large gaps in treatment. Primary care providers (PCPs) are ideally suited to diagnose and care for people with OUD and are increasingly being called upon to improve access to care. This review will highlight the recent literature pertaining to the care of patients with OUD by PCPs.

RECENT FINDINGS

The prevalence of patients with OUD in primary care practice is increasing, and models of office-based opioid treatment (OBOT) are evolving to meet local needs of both ambulatory practices and patients. OBOT has been shown to increase access to care and demonstrates comparable outcomes when compared to more specialty-driven care. OBOT is an effective means of increasing access to care for patients with OUD. The ideal structure of OBOT depends on local factors. Future research must explore ways to increase the identification and diagnosis of patients with OUD, improve treatment retention rates, reduce stigma, and promote interdisciplinary approaches to care.

A Cross-Sectional Web-Based Survey of Medical Practitioners in India to Assess their Knowledge, Attitude, Prescription Practices, and Barriers toward Opioid Analgesic Prescriptions

CONTEXT

Inadequate training of medical practitioners is a key factor responsible for inappropriate use of opioid analgesics.

AIMS

We assessed the current knowledge, attitude, prescribing practices, and barriers perceived by the Indian medical practitioners in three tertiary care hospitals toward the use of opioid analgesics.

SUBJECTS AND METHODS

Web-based survey of registered medical practitioner employed at three chosen tertiary health care institutions in New Delhi.

STATISTICAL ANALYSIS USED

Descriptive analysis of survey responses was carried out. Comparative analysis was done using Chi-square test, independent samples t-test, and Pearson correlation coefficient.

RESULTS

The response rate was 10.4% (n = 308). Two-thirds of the participants (61.7%) had never received formal pain management training, and 86.7% participants would like further training. Most participants (71.1%) agreed that opioids should be prescribed in cancer pain, while 26.3% agreed that opioids should be prescribed in noncancer pain. Half of the participants agreed that SOS (if necessary) dosing schedule (48.4%), low dosage (61.7%), and short duration of use (51.4%) could decrease the harmful effect of opioids. Lack of information about opioid-related policies and addiction potential were identified as the most common barriers to prescribing opioids. Those seeing more patients with chronic noncancer pain come across opioid misuse and diversion more often (P = 0.02). Those who understood addiction were more likely to agree that patients of chronic cancer pain with substance use disorders should be prescribed opioid analgesics (P < 0.01).

CONCLUSIONS

Indian medical practitioners felt the need for formal pain management training. There is a lack of consensus on how to manage the pain using opioid analgesics. Tough regulations on medical and scientific use of opioids are the most commonly reported barrier to prescribing them.

Opioids Use and Abuse: Prescription Practice, Attitude, and Beliefs among Doctors of Karachi

Background

Opioid analgesics, also known as narcotics, are medicinal drugs used primarily for the management of pain secondary to any type of cancer, severe injury or surgery. Due to the ease of availability, opioids are commonly abused. In 2015, reported deaths exceeded 33,000 Americans from opioid overdose. A survey in 2013 revealed nearly 1.6 million Pakistanis abusing prescription opioids for non-medical needs. Although commonly prescribed by primary care physicians, most of them are diffident to stand by all the recommended strategies to reduce the incidence of opioid abuse.

Methods

A cross-sectional study was conducted during the period of August through October 2018. A sample size of 365 was determined using a 95% confidence interval at a degree of precision of 5%. A 22-item questionnaire was given to doctors with at least two years practicing experience either from a private or a public healthcare setup. Doctors who had never prescribed opioids were excluded from the study. Out of the eligible participants, 15 refused to take part in the survey, and the co-operation rate was recorded as 95.8%. Collected data were analyzed using statistical package for social science (SPSS) version 22 for Windows. Frequencies, percentages, mean, standard deviation, and chi-square were used to explore the variables. The statistical significance level was considered at p < 0.5.

Results

Opioids were reported to be used mainly for treating acute pain (40.5%), chronic pain (24.7%) and both acute and chronic (34.8%). A minority of doctors (29%) screened their patients for opioid addiction. A significant association (p = 0.000) between the frequency of opioid prescription and prior screening for depression was determined. Surprisingly, only 23.2% clinicians frequently screened their patients for depression before prescribing opioids. The rate of counselling regarding drug tapering was found to be 71.6%. A majority, i.e., 88%, of the respondents anticipated the misuse of opioids they prescribe whereas 74% also held a belief that patients self-medicate their untreated pain. Participants reported addiction (54%) as the most common reason for abuse followed by the role of pharmaceutical companies (43%) and pharmacies (41%). About 80.2% clinicians believed that patients addicted to opioids could get well and return to their daily routine.

Conclusion

The rising opioid epidemic is a major concern for doctors prescribing opioids. Adaptation of medical school curricula and appropriate training can equip doctors for better management of patients requiring opioids. This includes the screening of patients using standard risk assessment tools for opioid abuse leading to a more controlled opioid prescription practice. Dissemination of these tools will boost doctors' confidence and may help in reducing morbidity and mortality from opioid abuse.

Characteristics of physicians who prescribe opioids for chronic pain: a meta-narrative systematic review

Background: The primary objective of this systematic review was to identify the characteristics of physicians who prescribe opioids to adults with chronic pain. This review was limited to studies examining fully-trained physicians, as relevant characteristics of resident physicians and non-physician clinicians may differ.

Methods: A comprehensive search of databases from January 1, 1980 to December 5, 2017 was conducted. Eligible study designs included (1) randomized trials; (2) nonrandomized prospective and retrospective studies; and (3) cross-sectional observational studies. The risk of bias in the included studies was assessed using an adapted version of the Newcastle-Ottawa Scale for cross-sectional studies. A total of 2508 records were screened and 22 studies met inclusion criteria. The majority of studies were cross-sectional (n=20) and the total number of participants was 8433.

Results: The risk of bias was high overall. The majority of physicians were confident managing and prescribing opioids for chronic pain but had high levels of dissatisfaction. Physicians reported high awareness of the potential for opioid misuse and were concerned about inadequate prior training in pain management. The majority of physicians were less likely to prescribe for patients with a history of substance abuse and reported major concerns about regulatory scrutiny.

Conclusion: This systematic review provides the foundation for the development of prospective studies aimed at further elucidating the constellation of mechanisms that influence physicians who manage pain and prescribe opioids.

Screening for Psychotherapeutic Medication Misuse in Primary Care Patients: Comparing Two Instruments

INTRODUCTION

Prescription psychotherapeutic medication misuse is a growing problem in the United States, but no method exists to routinely screen for this in primary care. Our study sought to (1) describe the prevalence of prescription psychotherapeutic medication misuse in primary care and the characteristics of patients who misuse and (2) compare 2 screening instruments modified to identify prescription medication misuse in primary care.

METHODS

Primary care patients from underserved, urban clinics within a health system completed anonymous computer-directed health screens that included standard questions about prescription medication misuse. They were also administered the 4-item Cut down, Annoyed, Guilty, and Eye-opener questionnaire modified to focus on prescription medications (RxCAGE) and a 6-item Prescription Opioid Misuse Index (POMI-e) expanded to include other prescription medications.

RESULTS

Of 2,339 respondents, 15.3% were positive for at least 2 items on the RxCAGE and 18.6% were positive for at least 2 items on the POMI-e. Using our computer-directed health screen as a comparison, we found that POMI-e had a higher area under the curve (0.63). A positive POMI-e was associated with being male, white and unemployed, having depression and anxiety, and currently using illicit substances, smoking, and misusing alcohol.

CONCLUSIONS

Rates of prescription medication misuse were substantial with both RxCAGE and POMI-e showing promise as screening instruments. Future studies are needed to test prescription medication misuse screening tools in broader populations and pilot interventions for those screening positive.

Provider perceptions of system-level opioid prescribing and addiction treatment policies

Stakeholders have implemented a multitude of system-level policies to address the U.S. opioid overdose epidemic. Because opioid prescribing partly fueled the crisis and because prescribing of medications for opioid addiction treatment is a key prevention strategy, it is critical to understand prescriber perceptions of policies in these domains. This article reviews prescriber awareness and opinions of the following system-level policies: opioid prescribing guidelines, prescription drug monitoring programs (PDMPs), medications for addiction treatment, and naloxone distribution programs. Most providers are aware of these policies, especially PDMPs, albeit a smaller proportion actively participate in their implementation. Low engagement in certain system-level policies is concerning and deserves attention, given that prescribers play an integral role in achieving optimal impact and mitigating the crisis.

Development and Validation of an Eight-Item Brief Form of the SOAPP-R (SOAPP-8)

Objective

Although the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) has become a widely used screener for aberrant opioid-related behavior in adults, the length of the instrument may limit its utility. The purpose of the current study was to develop a short form of the SOAPP-R by retaining as few items as possible while maximizing predictive accuracy.

Methods

Participants (N = 555), recruited from pain clinics, completed the 24-item SOAPP-R and participated in a five-month follow-up visit to evaluate aberrant drug-related behaviors. Opioid aberrant-related behavior was determined through self-report, physician report, and urine toxicology screen. The optimal subset of SOAPP-R items to predict aberrant opioid-related behavior was identified empirically by employing the LASSO selection method and the leave-one-out cross-validation (LOOCV) method offered in the GLMSELECT procedure in SAS 9.4 in conjunction with content expertise.

Results

Eight items were identified before the selection method stopped. The receiver operating characteristic curve generated from the predicted probabilities from the model produced an area under the curve (AUC) value greater than the AUC value produced by the 24-item SOAPP-R total score and yielded a sensitivity of 0.74 and a specificity of 0.66.

Conclusions

These results provide strong preliminary support for the SOAPP-8 as a brief screening tool of aberrant opioid-related behavior in chronic pain patients.

DSM-5 substance use disorders among adult primary care patients: Results from a multisite study

BACKGROUND

There are limited data about the extent of DSM-5 substance use disorders (SUDs) among primary care patients.

METHODS

This study analyzed data from a multisite validation study of a substance use screening instrument conducted in a diverse sample of 2000 adults aged ≥18 years recruited from five primary care practices in four states. Prevalence and correlates of 12-month DSM-5 SUDs were examined.

RESULTS

Overall, 75.5% of the sample used any substance, including alcohol (62.0%), tobacco (44.1%), or illicit drugs/nonmedical medications (27.9%) in the past 12 months (marijuana 20.8%, cocaine 7.3%, opioids 4.8%, sedatives 4.1%, heroin 3.9%). The prevalence of any 12-month SUD was 36.0% (mild disorder 14.2%, moderate/severe disorder 21.8%): tobacco 25.3% (mild 11.5%, moderate/severe 13.8%); alcohol 13.9% (mild 6.9%, moderate/severe 7.0%); and any illicit/nonmedical drug 14.0% (mild 4.0%, moderate/severe 10.0%). Among past 12-month users, a high proportion of tobacco or drug users met criteria for a disorder: tobacco use disorder 57.4% (26.1% mild, 31.3% moderate/severe) and any drug use disorder 50.2% (14.3% mild, 35.8% moderate/severe); a lower proportion of alcohol users (22.4%) met criteria for alcohol use disorder (11.1% mild, 11.3% moderate/severe). Over 80% of adults with opioid/heroin use disorder met criteria for a moderate/severe disorder. Younger ages, male sex, and low education were associated with increased odds of having SUD.

CONCLUSION

These findings reveal the high prevalence of SUDs in primary care and underscore the need to identify and address them.

Interprofessional prescription opioid abuse communication among prescribers and pharmacists: A qualitative analysis

BACKGROUND

Prescribers and community pharmacists commonly perceive prescription opioid abuse to be a problem in their practice settings and communities. Both cohorts have expressed support for interventions that improve interprofessional communication and reduce prescription opioid abuse. The objective of this study was to describe prescription opioid abuse-related communication among and between prescribers and community pharmacists in South Central Appalachia.

METHODS

The investigators conducted five focus groups with 35 Appalachian Research Network practice-based research network providers between February and October, 2014. Two prescriber-specific, two pharmacist-specific, and one interprofessional (prescribers and pharmacists) focus groups were conducted, recorded, and transcribed. Data collection and analysis occurred iteratively. Emerging themes were inductively derived and refined. Five member-checking interviews were conducted to validate themes.

RESULTS

Providers noted several factors that influence intraprofessional and interprofessional communication, including level of trust, role perceptions, conflict history and avoidance, personal relationships, and prescription monitoring program use. Indirect communication approaches via patients, office staff, and voicemail systems were common. Direct pharmacist to prescriber and prescriber to pharmacist communication was described as rare and often perceived to be ineffective. Prescriber to pharmacist communication was reported by prescribers to have decreased after implementation of state prescription monitoring programs. Difficult or uncomfortable conversations were often avoided by providers.

CONCLUSIONS

Interprofessional and intraprofessional prescription opioid abuse communication is situational and influenced by multiple factors. Indirect communication and communication avoidance are common. Themes identified in this study can inform development of interventions that improve providers' intra- and interprofessional communication skills.

[Misuse and dependence on prescription opioids: Prevention, identification and treatment]

Since the 1990s, the use of prescription opioids has largely spread, which has brought a real progress in the treatment of pain. The long-term use of prescription opioid is sometimes required, and may lead to pharmacological tolerance and withdrawal symptoms, i.e. pharmacological dependence on prescription opioids. Occasionally, this may also lead to misuse of prescription opioids (MPO). MPO preferentially occurs in vulnerable individuals, i.e., those with a young age, history of other addictive or psychiatric disorders, especially anxious and depressive disorders. MPO is associated with numerous complications, including an increased risk of fatal overdose. Prevention of MPO begins before the opioid prescription, with the identification of potential vulnerability factors. A planned and personalized monitoring should be systematically implemented. In vulnerable patients, contractualizing the prescription is warranted. During follow-up, the relevance of the prescription should be regularly reconsidered, according to the benefit observed on pain and the potential underlying signs of MPO. Patients with suspected MPO should be referred early to pain or addiction centers. The treatment of MPO should be based on multidisciplinary strategies, involving both the addiction and pain aspects: progressive opioid withdrawal, non-pharmacological measures against pain, or switching to medication-assisted treatment of addiction (i.e., buprenorphine or methadone).

Physician attitudes and experiences with Maryland's prescription drug monitoring program (PDMP)

AIMS

Physicians' use of prescription drug monitoring programs (PDMPs) varies by state. Among Maryland physicians, we sought to (1) estimate the PDMP impact on changes in opioid prescribing, (2) approximate the scope of PDMP utility and (3) determine the barriers to PDMP use after its 2013 implementation.

DESIGN

Cross-sectional postal survey linking responses to state records of PDMP registration and use, randomly sampling physicians within specialty and registration strata.

SETTING

Maryland, USA.

PARTICIPANTS

A total of 1000 surveyed primary care, pain and emergency medicine physicians stratified into three subpopulations: PDMP non-registrants, PDMP registrants who were non-users and PDMP users; 405 respondents (44%) of 916 eligible physicians were analysed.

MEASUREMENTS

Primary outcome measure was PDMP use. Key predictors were clinic characteristics, including type of practice and number of patients prescribed opioids.

FINDINGS

No response-wave bias was identified. Seventy per cent of physicians believed PDMP access decreased their amount and increased their comfort level in prescribing opioids. Three-fourths (74%) of PDMP users reported the data very useful for informing opioid prescribing, although one-fifth (20%) reported difficulty accessing the data. Commonly reported barriers to PDMP use were lack of knowledge regarding its existence and registration process. In multivariable analysis after adjusting for key clinic characteristics, practicing at a managed care organization was associated with lower PDMP use [incidence rate ratio (IRR) = 0.19, 95% confidence interval (CI) = 0.05-0.73]. Conversely, physicians who prescribed opioids for more than 50 patients accessed the PDMP three times as often as those prescribing opioids for fewer than 10 patients monthly (IRR = 3.00, 95 % CI = 1.07-8.43).

CONCLUSIONS

In this survey of Maryland, USA physicians, most participants reported that prescription drug monitoring programs (PDMPs) improved their opioid prescribing by decreasing prescription amounts and increasing comfort with prescribing opioids. Common barriers to PDMP use included not knowing about the program, registration difficulties and data access difficulties.

Mitigating the prescription drug abuse epidemic

Focused attention on the prescription drug abuse epidemic needs to include evidence-based training for clinicians who manage patients with pain to facilitate accurate screening with consideration of comorbid conditions, diagnosis, selection of the appropriate treatment regimen, and focused monitoring of adherence to the established course of therapy. DEA licensure requirements need to be amended to mandate targeted training focused on pain medication upon initial application and renewal of license. A nationwide mandated real-time dispenser database that requires verification every time a clinician prescribes opioids and other key controlled substances should be a top priority.

Primary care physicians' perspectives on the prescription opioid epidemic

BACKGROUND

Prescription opioid use disorder and overdose have risen substantially in the U.S. Primary care physicians are critical to many ongoing and proposed efforts to address the prescription opioid epidemic. Yet, little is known about their attitudes and beliefs surrounding this issue. This study aimed to determine primary care physicians' perceptions of the seriousness of the problem, its causes, groups responsible for addressing it, attitudes toward individuals with prescription opioid use disorder, beliefs about the effectiveness of addiction treatments, and support for various policies.

METHODS

We conducted a national web-based survey in 2014 among 1010 primary care physicians. We gauged responses to attitude and belief items on 7-point Likert scales. We examined the proportion agreeing with each statement, and whether responses differed among physicians prescribing higher and lower volumes of opioids.

RESULTS

Respondents largely attributed the causes of prescription opioid use disorder to individual-oriented factors and certain physician-oriented factors, and believed that individuals with prescription opioid use disorder and physicians were primarily responsible for addressing the problem. Negative attitudes toward people with prescription opioid use disorder were prevalent, but a majority believed that treatment could be effective. There was majority support for all measured policies, with the highest levels of support for policies to monitor prescribing among patients potentially at risk for an opioid use disorder and to improve physician education and training.

CONCLUSIONS

Given strong endorsement of recommended policies, physician support could be leveraged to advance efforts to curb prescription opioid use disorder and overdose.

Physician continuing education to reduce opioid misuse, abuse, and overdose: Many opportunities, few requirements

BACKGROUND

The opioid overdose epidemic in the United States is driven in large part by inappropriate opioid prescribing. Although most American physicians receive little or no training during medical school regarding evidence-based prescribing, substance use disorders, and pain management, some states require continuing medical education (CME) on these topics. We report the results of a systematic legal analysis of such requirements, together with recommendations for improved physician training.

METHODS

To determine the presence and characteristics of CME requirements in the United States, we systematically collected, reviewed, and coded all laws that require such education as a condition of obtaining or renewing a license to practice medicine. Laws or regulations that mandate one-time or ongoing training in topics designed to reduce overdose risk were further characterized using an iterative protocol

RESULTS

Only five states require all or nearly all physicians to obtain CME on topics such as pain management and controlled substance prescribing, and fewer than half require any physicians to obtain such training.

CONCLUSIONS

While not a replacement for improved education in medical school and post-graduate clinical training, evidence-based CME can help improve provider knowledge and practice. Requiring physicians to obtain CME that accurately presents evidence regarding opioid prescribing and related topics may help reduce opioid-related morbidity and mortality. States and the federal government should also strongly consider requiring such training in medical school and residency.

Patients' Perspectives on Tapering of Chronic Opioid Therapy: A Qualitative Study

OBJECTIVE : There is inadequate evidence of long-term benefit and growing evidence of the risks of chronic opioid therapy (COT). Opioid dose reduction, or opioid tapering, may reduce these risks but may also worsen pain and quality of life. Our objective was to explore patients' perspectives on opioid tapering. DESIGN : Qualitative study using in-person, semistructured interviews. SETTING AND PATIENTS : English-speaking, adult primary care patients (N = 24) in three Colorado health care systems. METHODS : Interviews were audio recorded, transcribed, and analyzed in ATLAS.ti. We used a team-based, mixed inductive and deductive approach guided by the Health Belief Model. We iteratively refined emergent themes with input from a multidisciplinary team. RESULTS : Participants had a mean age of 52 years old, were 46% male and 79% white. Six participants (25%) were on COT and not tapering, 12 (50%) were currently tapering COT, and 6 (25%) had discontinued COT. Emergent themes were organized in four domains: risks, barriers, facilitators, and benefits. Patients perceived a low risk of overdose and prioritized the more immediate risk of increased pain with opioid tapering. Barriers included a perceived lack of effectiveness of nonopioid options and fear of opioid withdrawal. Among patients with opioid tapering experience, social support and a trusted health care provider facilitated opioid tapering. These patients endorsed improved quality of life following tapering. CONCLUSIONS : Efforts to support opioid tapering should elicit patients' perceived barriers and seek to build on relationships with family, peers, and providers to facilitate tapering. Future work should identify patient-centered, feasible strategies to support tapering of COT.

Prescription drug abuse communication: A qualitative analysis of prescriber and pharmacist perceptions and behaviors

BACKGROUND

Interpersonal communication is inherent in a majority of strategies seeking to engage prescriber and pharmacist health care professionals (HCPs) in the reduction and prevention of prescription drug abuse (PDA). However, research on HCP PDA communication behavioral engagement and factors that influence it is limited.

OBJECTIVES

This study quantitatively examined communication behaviors and trait-level communication metrics, and qualitatively described prescription drug abuse-related communication perceptions and behaviors among primary care prescribers and community pharmacists.

METHODS

Five focus groups (N = 35) were conducted within the Appalachian Research Network (AppNET), a rural primary care practice-based research network (PBRN) in South Central Appalachia between February and October, 2014. Focus groups were structured around the administration of three previously validated trait-level communication survey instruments, and one instrument developed by the investigators to gauge HCP prescription drug abuse communication engagement and perceived communication importance. Using a grounded theory approach, focus group themes were inductively derived and coded independently by study investigators. Member-checking interviews were conducted to validate derived themes.

RESULTS

Respondents' trait-level communication self-perceptions indicated low communication apprehension, high self-perceived communication competence, and average willingness to communicate as compared to instrument specific criteria and norms. Significant variation in HCP communication behavior engagement was noted specific to PDA. Two overarching themes were noted for HCP-patient communication: 1) influencers of HCP communication and prescribing/dispensing behaviors, and 2) communication behaviors. Multiple sub-themes were identified within each theme. Similarities were noted in perceptions and behaviors across both prescribers and pharmacists.

CONCLUSIONS

Despite the perceived importance of engaging in PDA communication, HCPs reported that prescription drug abuse communication is uncomfortable, variable, multifactorial, and often avoided. The themes that emerged from this analysis support the utility of communication science and health behavior theories to better understand and improve PDA communication behaviors of both prescribers and pharmacists, and thereby improve engagement in PDA prevention and treatment.