Chronic Opioid Prescribing in Primary Care Varies Widely

June 04, 2019 10:12 pm Chris Crawford – Chronic opioid prescribing in primary care varies significantly by patient and clinician characteristics.

Furthermore, blacks/African Americans constituted a disproportionally high percentage of patients in the study who received chronic opioids -- at 43.1% -- compared with representing only 14.7% of the 84,027 patients in the study who did not. White patients, on the other hand, comprised 48.2% of those who received chronic opioids, but made up 57.4% of those who did not.

In urban underserved clinics, nearly 10% of all prescriptions written were for opioids, compared with only 3% of prescriptions written in suburban clinics.

Family physician and study lead author Sebastian Tong, M.D., M.P.H., of Syracuse, N.Y., told AAFP Newsthat multiple factors probably explain the discrepancy between urban and suburban opioid prescribing patterns.

"One of them is that more affluent populations have access to nonopioid treatment modalities that may not be covered by insurance," he said. "There may also be differences in cultural expectations for treatment of pain."

Of the risk factors identified by the CDC's 2016 Guideline for Prescribing Opioids for Chronic Pain, the authors said comorbidities such as sleep apnea, depression or anxiety, substance use disorder, hepatic or renal insufficiency, and concurrent benzodiazepine use were associated with receiving chronic opioids.

Moreover, patients with these specific comorbidities -- depression or anxiety, substance use disorder, hepatic insufficiency, and renal insufficiency -- were more likely than those without them to receive higher overall morphine milligram equivalents of chronic opioids per day.

"One of the reasons why those with higher comorbidities may be more likely to receive chronic opioid prescriptions is that they have contraindications to medications that are nonopioid," Tong said. "For example, those with renal insufficiency cannot take nonsteroidal anti-inflammatory drugs."

Tong said he thought it was most interesting that being black or African American was associated with being prescribed chronic opioids, because acute opioid prescribing trends seen in previous studies indicate that white patients are more likely than black or African American patients to receive opioids in emergency department settings and overall.

"Having depression and/or anxiety or substance use disorder is known to change pain tolerance and perception, which may cause some of the association with chronic opioid prescribing," he added.

Physicians Describe Frustrations

Clinician interviews revealed multiple factors that informed their use of prescription opioids for chronic pain in primary care, the study said.

Tong said physicians indicated frustration regarding chronic opioid prescribing because of demands from patients that frequently conflict with new guidance restricting opioid prescribing.

It bears noting here that the CDC recently published a commentary in the New England Journal of Medicine that warned about misapplication of its opioid prescribing guideline, including that the agency wasn't suggesting instituting hard limits or cutting off opioid use in patients with chronic pain.

Clinicians also said they saw the use of opioids to manage chronic pain as appropriate when caring for patients with extensive medical comorbidities or those for whom nonopioid pain medications were contraindicated.

However, the study noted, despite the perceived benefits of opioids, most clinicians were reluctant to start patients on opioids for chronic pain; instead they reported having inherited the bulk of their patients with chronic pain from colleagues.

"Many physicians felt that primary care is often becoming the default prescriber when other specialists back out, that there is limited systemic support to help them reduce prescribed opioid use in their patients and that the guidelines do not consider patients they may have cared for over many years at a stable, yet high, dose of chronic opioids," Tong said.

Furthermore, the study said primary care clinicians' frustrations were compounded by a perceived lack of time to appropriately manage patients' chronic pain and a lack of control over patients' access to other sources of opioids, such as hospitals or subspecialists.

Call for More Research

Finally, the authors called for additional research to explore trends in opioid prescribing, compare differences in opioid prescribing in various settings and test interventions to help primary care clinicians overcome barriers in weaning patients at high risk for opioid-related harms.

"While there are now guidelines from both the CDC and many state boards of medicine on what constitutes appropriate opioid prescribing, there remains a gap between ideal practices and the day-to-day reality in primary care practices," Tong said. "Research on interventions to help primary care clinicians implement guidelines into actual practice will also help lower risks of opioid-related harms in patients."