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 constructed 3 models to predict willingness to prescribe opioids. In Model 1 the dependent variable to designate willingness to prescribe was constructed from the sum of responses to the 5-point Likert-scaled question asked after each of the 3 vignettes: “If the pain persisted unchanged, would you prescribe opioids for this patient on a long-term basis?” In Model 2 the dependent variable was defined according to the range of agreement on a 5-point Likert scale with the following statement: “For patients with CNMP that persists unchanged after exhaustive evaluation and attempts at treatment, I am willing to prescribe opioids not requiring triplicates (such as Tylenol with codeine) on an as-needed basis.” In Model 3, the dependent variable was defined according to the range of agreement with the following statement on a 5-point Likert scale: “For patients with CNMP that persists unchanged after exhaustive evaluation and attempts at treatment, I am willing to prescribe opioids requiring triplicates (eg, fentanyl patch, methadone, or sustained-release morphine) on a fixed, around-the-clock basis.”

Results

Physician and Practice Characteristics

A total of 161 of 230 physicians (70%) completed the survey. The demographic characteristics of the respondents are presented in Table 2. Table 3 shows physician estimates of patient demographics in their practices. As a group the CRN physicians were mostly white men, but they care for an ethnically, financially, and age-diverse population. The large SDs in Table 3 reflect the wide variety of practice types included in the CRN membership.

Physicians reported seeing an average of 280 patients (SD=157), including 18 CNMP patients (SD=26), per month. An average of 7 patients (SD=8) with CNMP were prescribed opioid analgesics per month, and 90% of the physicians reported prescribing opioids for CNMP at least once a month. The wide SDs again reflect broad variation in the number of patients seen, the number of patients encountered with CNMP, and the number of patients treated with opioid analgesics by different physicians.

Attitudes and Practices of Physicians

Only 15% of respondents agreed with the statement: “I enjoy working with patients who have CNMP.” However, only 15% also felt that daily opioids have no place in the treatment of CNMP. Only 7% agreed with the statement: “I never prescribe opioids for CNMP.”

Many physicians wait for their patients to bring up the subject of opioid treatment, as indicated by the fact that 41% of the respondents agreed that “most of my patients who get opioid prescriptions from me for CNMP requested an opioid before I suggested their use.” In addition, 37% responded that they rarely or never are the first physician to prescribe opioids to their patients with CNMP, possibly waiting for other specialists to take the initiative.

The responses to questions about the 3 clinical vignettes are presented in Table 4. Nearly all physicians felt that the vignettes were realistic, and most believed they were knowledgeable about evaluation and treatment for these patients. However, each case generated substantial variation of opinion with regard to the level of optimism about being able to help the patient, the need for specialty referral, and the willingness to treat with opioids. For each vignette respondents were generally more concerned about physical dependence, tolerance, and addiction than they were about diversion for illegal use, regulatory scrutiny, or side effects. However, physicians’ level of concern about each of these outcomes varied substantially for each vignette.

The physicians were asked general questions about situations in which they would never prescribe opioids. Although none of the respondents said that they had a policy of refusing opioids to patients aged older than 65 years, 19% said they would never prescribe opioids to a child younger than 18 years. In addition, 16% said they would never prescribe opioids to a previous substance abuser, and 42% said they would never prescribe opioids to a current substance abuser, even if recommended by an appropriate specialist.

Also, respondents expressed an increased reluctance to prescribe opioids to CNMP patients as the frequency and potency of the medication was increased. Although only 2% of physicians said they would never prescribe low-potency (schedule III) opioids on an as-needed basis, 35% said they would never prescribe high-potency (schedule II) opioids around the clock, even after exhaustive evaluation and attempts at treatment.

In addition, the willingness of respondents to prescribe opioids varied according to the medical condition being treated. Forty-two percent of respondents said they would never prescribe long-acting schedule II opioids to a patient with post-herpetic neuralgia; 57% would never prescribe them for chronic low back pain; and 75% would never prescribe them for chronic daily headache.