Pain Docs Have Highest Ratio of Patient Deaths to Opioid Rx

Kate Johnson

March 01, 2012

February 29, 2012 (Palm Springs, California) — Despite writing only a small proportion of all opioid prescriptions, pain medicine doctors have the highest ratio of opioid overdose deaths among their patients on active prescriptions, according to a study of the Utah Controlled Substance Database.

"Pain medicine is over-represented in these deaths compared to what we would expect based on their prescribing," said lead author Christy Porucznik, PhD, who presented her findings at the American Academy of Pain Medicine (AAPM) 28th annual meeting here.

"In one sense, that surprised the heck out of me, because you would think these are the docs with the most experience," said Dr. Porucznik, from the University of Utah, Salt Lake City. "But on the flip side, they are probably taking care of the most complicated patients," she said in an interview with Medscape Medical News.

Dr. Christy Porucznik

The study, which raised some hackles in the poster hall, used data from the Utah Controlled Substance Database (2005 to 2009) and the National Provider Identifier to find the specialties of opioid prescribers. It then linked this information to records of opioid overdose deaths from the Utah Medical Examiner.

From a total of 30,299,216 records, the analysis showed that family medicine physicians wrote the largest proportion of prescriptions (24.9%), followed distantly by internal medicine physicians (10.7%) and then dentists (8.8%) and nurse practitioners (6.1%).

The largest proportion of opioid-overdose deaths were also associated with prescriptions from family medicine physicians (36.5%) followed by nurse practitioners (11.7%), physician's assistants (9.7%), and internal medicine physicians (9.5%).

But when considering the ratio of opioid-overdose deaths to active opioid prescriptions, pain medicine topped the list.

Although pain medicine specialists wrote only 1% of opioid prescriptions, those prescriptions were associated with 3% of opioid-overdose deaths — a ratio of 3.00 active opioid prescriptions for decedents to prescriptions — compared with lower ratios for other specialties, said Dr. Porucznik.

For example, despite high prescribing and fatality rates, family medicine's death-to-prescription ratio was 1.46. Still, the researchers note that any ratio above 1.00 means that the specialty is associated with more deaths than expected on the basis of its prescribing.

After pain medicine specialists, anesthesiologists had the second highest death-to-prescription ratio (2.47), followed by physical medicine and rehabilitation practitioners (2.18) and nurse practitioners (1.89).

"We can't look at this and point a finger at pain medicine and say they're the only ones who need prescribing education," said Dr. Porucznik. "My guess would be their patients are more complicated, but based on this prescription registry we don't have good data about the diagnosis."

Their next step is to separate out prescriptions for acute vs chronic care, she said, "because a good chunk of this family medicine prescribing might be for things like a broken arm where you're only taking it for a few days as opposed to somebody who is trying to manage chronic pain over a long period of time."

Higher Doses, Complex Patients

Asked to comment on the findings Michael Brennan, MD, and Sidney Schnoll, MD, PhD, said they were "provocative" but lack some of the information required for interpretation.

"This is an association and an association is not cause," said Dr. Schnoll, vice president of pharmaceutical risk management services for Pinney Associates, Inc, and clinical professor of internal medicine and psychiatry at the Medical College of Virginia, Virginia Commonwealth University, Richmond.

"Yes, the pain physicians are prescribing these drugs probably in higher doses to more complex patients and there's greater chance of having a fatality," he told Medscape Medical News. "But you cannot attribute opioids as a cause of death unless you know the level of tolerance the patient has."

"What they're measuring is controlled substances through their prescription drug monitoring program. That's the only thing. They have no idea what other drugs these people are on," he added.

Dr. Brennan, from the Pain Center of Fairfield, and senior attending physician at Bridgeport Hospital in Fairfield, Connecticut, said "pain patients are generally sicker, more complicated, are on more drugs, and have more comorbid psychiatric issues."

And he agreed that a "toxic level" of opioid is very different in pain patients than others.

"I used to get urgent calls from the lab saying my patients had toxic levels of drug in their system and yet my patient was working 40 hours a week driving a truck and having no issues. So we don't have a parameter that says somebody has a true toxic level or not — and medical examiners aren't pain doctors."

Still, Dr. Porucznik pointed out that "pain medicine specialists are not immune to adverse events."

"It may be that pain medicine physicians feel they already know everything about prescribing opioids and don't need any more education or practice, and that may not be accurate as new drugs become available," she said. "It may not be that opioids are different, but maybe it's the new drug treating their patient's diabetes that interacts with the opioid."

Funding for the study was provided by the Utah Department of Health  and the Centers for Disease Control and Prevention. Dr. Porucznik had disclosed no relevant financial relationships. Dr. Schnoll is a paid employee of Pinney Associates, which provides consultation to numerous pharmaceutical companies but does not receive any direct support from them. Dr. Brennan is a speaker for Jansen/J&J, Pfizer, Lilly, Forrest Labs, Depomed, Millenium and AFTI; he is a consultant and serves on the speaker's bureau for Purdue Pharma, Covidien, Teva/Cephalon, and Endo; and he owns stock with Apricus Biosciences and Pain Therapeutics.

American Academy of Pain Medicine 28th Annual Meeting: Abstract #201. Presented February 24, 2012.

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