We asked about the use of specialists to assist in the evaluation and treatment of patients who may benefit from opioid treatment for CNMP. Fifty-two percent of the physicians reported always or usually requiring their patients to undergo evaluation by a specialist before prescribing opioids on an ongoing basis for CNMP. Yet only 55% felt they had adequate consultation and referral resources to assist with patients who have CNMP. In addition, only 29% felt they had adequate consultation and referral resources in their communities to assist them with patients who might be abusing or selling opioid prescriptions.
Familiarity with State Prescribing and Documentation Guidelines
In 1994, the Medical Board of California issued guidelines for prescribing opioids for CNMP that were designed to standardize referral and documentation practices and to reduce fear of regulatory scrutiny among physicians who prescribe opioids for CNMP. The guidelines were mailed to all licensed physicians in the state on 3 occasions between 1994 and 1996.23 We found that 39% of respondents remembered reading the guidelines 1 year after the third mailing. We also found that physicians varied in their self-reported compliance with recommended documentation practices. Ninety percent said they always or usually document a history and physical examination before prescribing opioids, and 86% document periodic reassessment of chronic pain. However, only 60% said that they always or usually document rules of use and misuse of opioid medications; 45% document treatment objectives; and 24% document informed consent. When asked about regulatory scrutiny, 40% of physicians agreed that fear of legal investigation tempers their use of opioids for patients with CNMP.
Predictors of Willingness to Prescribe Opioids
Three models were postulated to clarify the determinants of willingness to prescribe opioids for CNMP. The results of these analyses are presented in Table 5. The stepwise linear regression for each model generated a value for each variable (R2) that represents the proportion of the variance that can be explained by the given variable.
In all 3 models lower levels of concern about physical dependence in response to the vignettes were associated with greater willingness to prescribe opioids. Other variables that were significant predictors of willingness to prescribe opioids in 1 or more models were more recent graduation from medical school, enjoyment in working with chronic pain patients, less fear of regulatory scrutiny, and fewer total patients seen per month.
Discussion
Nearly all the physicians in our sample were willing to treat certain CNMP patients with schedule III opioids on an as-needed basis. However, a third of these physicians said they never use the more potent long-acting schedule II opioids for CNMP. There was also substantial disagreement about which patients would benefit from opioids and which might be likely to suffer adverse effects.
Concern about physical dependence appears to be among the most important barriers to the use of opioids for patients with CNMP. Whether this is always an appropriate concern is debatable. For example, in the case of using schedule III opioids on an as-needed basis, the lack of continuous exposure should limit the risk of physical dependence.
Our finding that physician concerns about physical dependence, tolerance, and addiction were highly intercorrelated raises the possibility that many physicians believe, correctly or incorrectly, that these 3 conditions are closely related effects of opioids. It is also possible that physicians are unclear about what distinguishes one of these outcomes from another. More research is needed to determine the root of physician concerns about physical dependence, tolerance, and addiction. Although all 3 of these outcomes can result when opioids are used around the clock, they nonetheless do not always occur together or necessarily all have equally serious implications when they occur.24 Only a slight majority of respondents felt that they had adequate consultation and referral resources in their community to assist with patients who have CNMP. Primary care physicians may benefit from more information about pain management resources in their communities. In addition, communities without these resources may benefit from the development of pain management centers that can assist primary care physicians with patients who suffer from CNMP.
More recent graduation from medical school was a predictor of increased willingness to prescribe opioids. Recently trained physicians may be more likely to have been exposed to an environment of more liberal use of opioids for CNMP. Conversely, the decreased willingness of more experienced physicians to prescribe opioids may be influenced by their clinical experiences with the complications of opioid use.
Fear of regulatory scrutiny also appeared to limit willingness to prescribe as-needed low-potency schedule III opioids. Recent laws and guidelines have attempted to reduce both the risk and fear of regulatory scrutiny when opioids are prescribed for chronic pain.23,25,26 However, it is not clear whether awareness of these guidelines would increase or decrease physician concern with regard to regulatory scrutiny, since many physicians reported that their documentation standards are not up to those recommended. In addition, we found no differences in willingness to prescribe opioids based on awareness of the guidelines in California.