Tuesday, December 9, 2014

Nine in 10 primary care physicians say that prescription drug abuse is a moderate or big problem in their communities and nearly half say they are less likely to prescribe opioids to treat pain compared to a year ago, new Johns Hopkins Bloomberg School of Public Health research suggests.

Primary care doctors also appear to recognize many risks of prescription opioid use, including addiction and death by overdose, according to the findings reported in the Dec. 8 issue of JAMA Internal Medicine.

“Our findings suggest that primary care providers have become aware of the scope of the prescription opioid crisis and are responding in ways that are important, including reducing their overreliance on these medicines,” says study leader G. Caleb Alexander, MD, MS, an associate professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health and co-director of Johns Hopkins’ Center for Drug Safety & Effectiveness. “The health care community has long been part of the problem and now they appear to be part of the solution to this complex epidemic.”

Prescription drug abuse is the nation’s fastest growing drug problem, according to a report released by the White House a few years ago. According to the U.S. Centers for Disease Control and Prevention, drug overdose death rates in the United States have more than tripled since 1990 and have never been higher. The clinical use of prescription opioids nearly doubled between 2000 and 2010, and in 2010, more than 38,000 people died from drug overdoses of all kinds, with many of these deaths caused by prescription opioids.

Only in recent years has the medical community paid much attention to the mounting epidemic, the researchers say.

For their research, Alexander and his colleagues sent surveys in February 2014 to a nationally representative sample of 1,000 U.S. internists, family physicians and general practitioners, with 58 percent responding.

Among the findings: A large majority of the respondents – 85 percent – say they believe that opioids are overused in clinical practice. Many reported they are “very” or “moderately” concerned about serious risks such as addiction (55 percent reporting “very concerned”), death (48 percent) and motor vehicle crashes (44 percent) that may be associated with opioid overuse. Many also reported they believe that adverse events, such as tolerance (62 percent) and physical dependence (56 percent) occur “often,” even when the medications are used as directed for chronic pain.

Surprisingly, despite concerns about overprescribing, nearly all physicians surveyed (88 percent) expressed confidence in their own ability to prescribe opioids appropriately.  Such attitudes may reflect the fact that doctors tend to perceive their own clinical skills and judgment as superior to that of their peers. For example, physicians’ “ego bias” has been demonstrated in the setting of engagements with pharmaceutical manufacturers. Prior studies have shown that most doctors believe their colleagues’ prescribing decisions are swayed by pharmaceutical marketing and promotion, yet they themselves are immune to such effects.

Alexander says he hopes more physicians and patients look toward more non-opioid treatments for pain, such as other types of pain relievers and non-drug treatments including physical therapy, massage and acupuncture.

Meanwhile, he says more research is needed. While there is good value in surveying physicians about their attitudes, beliefs and experiences, he says research using pharmacy data is needed to confirm the degree to which prescribers’ reliance on prescription opioids is actually decreasing.

“Prescription Drug Abuse: A National Survey of Primary Care Physicians” was written by Catherine S. Hwang, MSPH; Lydia W. Turner, MHS; Stefan P. Kruszewski, MD; Andrew Kolodny, MD; and G. Caleb Alexander, MD, MS.

Hwang is an ORISE Fellow at the Food and Drug Administration. Kruszewski has served as a general and case-specific expert for multiple plaintiff litigations involving OxyContin, Neurontin, and Zyprexa and has had false claims settled as co-plaintiff with the United States against Southwood Psychiatric Hospital, Pfizer (Geodon), and AstraZeneca (Seroquel). Kolodny is chief medical officer at Phoenix House and director of Physicians for Responsible Opioid Prescribing. Alexander is Chair of the Food and Drug Administration’s Peripheral and Central Nervous System Drugs Advisory Committee, serves as a paid consultant to IMS Health, and serves on an IMS Health scientific advisory board. This arrangement has been reviewed and approved by Johns Hopkins University in accordance with its conflict of interest policies.