Original Research

Opioids for Chronic Nonmalignant Pain

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Attitudes and Practices of Primary Care Physicians in the UCSF/Stanford Collaborative Research Network


 

References

BACKGROUND: We hoped to determine the attitudes and practices of primary care physicians regarding the use of opioids to treat chronic nonmalignant pain (CNMP). We also examined the factors associated with the willingness to prescribe opioids for CNMP.

METHODS: A survey was mailed to primary care physicians in the University of California, San Francisco/Stanford Collaborative Research Net- work. This survey contained questions regarding treatment in response to 3 case vignettes, the use of opioids for CNMP in general, and the demographic characteristics of the physicians.

RESULTS: Among 230 physicians surveyed, 161 (70%) responded. Two percent of the respondents were never willing to prescribe schedule III opioids (eg, acetaminophen with codeine) as needed for patients with CNMP that persisted unchanged after exhaustive evaluation and attempts at treatment. Thirty-five percent were never willing to prescribe schedule II opioids (eg, sustained-release morphine) on an around-the-clock schedule for these patients. The most significant predictor of willingness to prescribe opioids for patients with CNMP was a lower level of concern about physical dependence, tolerance, and addiction.

CONCLUSIONS: Primary care physicians are willing to prescribe schedule III opioids as needed, but many are unwilling to use schedule II opioids around the clock for CNMP. Individual prescribing practices vary widely among primary care physicians. Concerns about physical dependence, tolerance, and addiction are barriers to the prescription of opioids by primary care physicians for patients with CNMP.

Opioids are effective analgesics that are widely accepted as therapy for cancer pain and pain related to other terminal illnesses.1-2 However, the use of opioids to treat chronic nonmalignant pain (CNMP) is controversial.3-8 Few clinical studies of opioids in the alleviation of CNMP have been conducted, and most have been small, retrospective, uncontrolled, or focused on patients seen in referral settings.9-21 Together these studies suggest that opioids may benefit certain patients with CNMP, though the results have not been conclusive.

In clinical practice the absence of definitive data on the risks and benefits of opioids for CNMP presents a dilemma. Decisions about potency, frequency, and duration of treatment must be made without the benefit of evidence-based guidelines and with the knowledge that state medical boards or other legal authorities may scrutinize opioid prescriptions. We conducted this study to learn more about attitudes, prescribing practices, and factors associated with the willingness of primary care physicians to prescribe opioids for their patients with CNMP.

Methods

Sample

The University of California, San Francisco/Stanford Collaborative Research Network (CRN) is a practice-based research network composed predominantly of family physicians practicing in Northern and Central California. In 1997 the CRN conducted this survey of all 230 primary care physician members who were not involved in designing our study. Up to 2 mailed reminders and 3 telephone calls were made to initial nonresponders to improve the response rate.

Instrument

The survey instrument was developed through a collaborative process involving 7 volunteer physicians from the CRN. It was pilot-tested and refined using focus groups of practicing non-CRN primary care physicians.

On the first page of the survey, CNMP was defined as pain lasting longer than 6 months that was not related to cancer or another condition expected to end a patient’s life within 6 months. The survey included 3 clinical vignettes Table 1 designed to evoke responses to a variety of patient characteristics, such as medical history, age, sex, and socioeconomic status. Each vignette was followed by a set of specific questions. The survey also contained questions unrelated to the vignettes, regarding general attitudes toward opioids and opioid prescribing practices. We asked about documentation practices, referral resources, and familiarity with state guidelines. The respondents were also queried about personal, patient, and practice characteristics.

Statistical Analysis

We conducted analyses using SAS software.22 Means and standard deviations (SDs) for continuous variables, and frequency distributions for categorical variables, were calculated to summarize physician respondent characteristics, estimates of the characteristics of their caseloads, and summaries of their responses to questions about the clinical vignettes. We used correlation coefficients to examine the strength of relationships between attitudes and practice. The results of the correlation coefficients were used to choose a set of independent variables that were most predictive of willingness to prescribe opioids for CNMP.

We examined with stepwise linear regression the association between willingness to prescribe opioid medications and specific physician characteristics, including year of medical school graduation, size of patient caseload, and concerns about physical dependence, tolerance, addiction, side effects, regulatory scrutiny, and diversion for illegal use. In selecting the final set of variables for the stepwise linear regression predicting willingness to prescribe opioids for CNMP, we found that concern about physical dependence, tolerance, and addiction were highly intercorrelated. Among these variables, concern about physical dependence was the most consistently predictive of willingness to prescribe opioids for CNMP. When concern about physical dependence was entered into stepwise models the variables measuring concern about tolerance and addiction dropped out. Therefore, we chose to use concern about physical dependence as a proxy for measuring generalized concerns about all 3 concerns taken together.

Pages

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