Abstract
Opioid musculoskeletal pain overprescribing was widespread in the mid-2000s. The degree to which prescribing changed as awareness of the danger grew among physicians with different levels of clinical knowledge remains unstudied. To compare the association of clinical knowledge with opioid prescribing from 2009 to 2011 when prescribing peaked nationally with 2015 to 2017 when guidelines shifted away from opioid prescribing. This cross-sectional study included 10 246 midcareer general internal medicine physicians in the United States who saw patients who were Medicare beneficiaries with Part D enrollment from 2009 to 2017. Any opioid prescription and high dosage or long duration (HDLD) (>7 days or >50 daily morphine milligram equivalents) opioid prescriptions filled within 7 days of applicable visits for new low back pain concerns. Associations between opioid prescribing for new low back pain concerns during outpatient visits and clinical knowledge measured by prior year American Board of Internal Medicine (ABIM) Maintenance of Certification examination performance were estimated using serial cross-sectional logit regressions. Regression covariates included yearly examination quartile (ie, knowledge quartile) interacted with 3-year group dummies (ie, early: 2009-2011; middle: 2012-2014; late: 2015-2017), state and year dummies, physician, practice, patient characteristics, and state opioid regulations. Of the 55 387 low back pain visits included in this study, 37 185 (67.1%) were visits with female patients, 41 978 (75.8%) were with White patients, and the mean (SE) age of patients was 76.2 (<0.01) years. The rate of opioid prescribing was 21.6% (11 978) for any opioid prescription and 17.6% (9759) for HDLD prescriptions. From 2009 to 2011, visits with physicians in the highest and lowest knowledge quartiles had similar adjusted opioid prescribing rates with a 0.5 (95% CI, -1.9 to 3.0) percentage point difference. By 2015 to 2017, visits with physicians in the highest knowledge quartile prescribed opioids less frequently that physicians in the lowest knowledge quartile (4.6 percentage point difference; 95% CI, -7.5 to -1.8 percentage points). Visits in which HDLD opioids were prescribed showed no difference in the early period but showed a difference in the late period when comparing physicians in the highest and lowest knowledge quartiles (early period: difference -0.1; 95% CI, -2.4 to 2.2 percentage points; late period difference: 4.8; 95% CI, -7.4 to -2.1 percentage points). In this cross-sectional study, when the standard of care shifted away from routine opioid prescribing, physicians who performed well on an ABIM examination were less likely to prescribe opioids for back pain than physicians who performed less well on the examination.
Highlights
Opioid overprescribing in the early 2000s is considered to be a major contributor to the genesis of the modern opioid use disorder crisis.[1,2,3,4] Experts believe that opioid overprescribing was fueled in part by pharmaceutical manufacturer–supported advocacy that pain was widely undertreated and that opioids, especially oxycodone, were marketed to primary care physicians as a safe and effective means to reduce unnecessary pain.[3,5,6,7,8] This advocacy was accompanied by broad guideline changes during the late 1990s and early 2000s that promoted the use of opioids for pain management
From 2009 to 2011, visits with physicians in the highest and lowest knowledge quartiles had similar adjusted opioid prescribing rates with a 0.5 percentage point difference
Visits in which high dosage or long duration (HDLD) opioids were prescribed showed no difference in the early period but showed a difference in the late period when comparing physicians in the highest and lowest knowledge quartiles
Summary
Opioid overprescribing in the early 2000s is considered to be a major contributor to the genesis of the modern opioid use disorder crisis.[1,2,3,4] Experts believe that opioid overprescribing was fueled in part by pharmaceutical manufacturer–supported advocacy that pain was widely undertreated and that opioids, especially oxycodone, were marketed to primary care physicians as a safe and effective means to reduce unnecessary pain.[3,5,6,7,8] This advocacy was accompanied by broad guideline changes during the late 1990s and early 2000s that promoted the use of opioids for pain management. After 2011, more evidence pointed to the routine prescribing of opioids as likely contributing to a dramatic increase in opioid-related deaths.[14] The prevailing culture toward opioid prescribing began to shift to the point where, by 2015, leading medical societies were changing their guidelines and guidance to recommend against routine prescribing of opioids for pain in favor of safer alternatives.[14,15,16,17,18,19] For example, in 2015, the American Academy of Orthopedic Surgeons released an advisory outlining new guidelines for opioid prescriptions for muscular skeletal conditions warning of the dangers of opioid prescriptions.[15] In 2016, the US Centers for Disease Control and Prevention published widely circulated opioid prescribing guidelines for chronic pain, and the US Food and Drug Administration had begun requiring a new boxed warning for opioid medications detailing their serious risks of addiction and overdose.[19] In 2017, the American College of Physicians changed its opioid prescribing guidelines that had been in place since 2007 and argued against opioid use for lower back pain (LBP).[17] Despite this substantial shift in guidelines and growing evidence raising concern about routine opioid use, opioid prescribing remains highly variable among physicians.[20,21]
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