Survey: Doctors, NPs, Patients Concerned About Opioid Dangers

Pauline Anderson

December 30, 2015

The majority of doctors and other health professionals are very (74%) or somewhat (24%) concerned about the increased abuse, misuse, and diversion of opioid analgesics, such as hydrocodone and oxycodone, a new Medscape survey shows.

But while most professionals discuss with patients how and when to take these drugs (91%) and their possible side effects (93%), far fewer (55%) discuss safe storage and proper disposal, the survey showed.

Meanwhile, a similar survey by WebMD showed that 4 in 10 (42%) consumer respondents said they store unused pills for future use, contributing to a "national inventory" of unused opioids, the summary document notes. Only 23% report returning unused opioids to pharmacies with disposal programs or throwing them away.

The WebMD survey showed 63% of consumer respondents have used an opioid and that about a third (35%) used such a drug in the past 3 years. Most of these recent users (92%) reported having tried alternatives, such as over-the-counter medications, topical prescriptions, and alternative medicines, but only about a quarter (26%) said these were effective.

WebMD and Medscape are divisions of WebMD Health; Medscape owns Medscape Medical News.

The survey was undertaken on the background of two disturbing trends:

  • Skyrocketing rates of opioid prescriptions. Prescriptions rose from 76 million in 1991 to 219 million in 2011, according to IMS Health, a company that tracks pharmaceutical sales data.

  • Increasing deaths from opioid overdoses. Data from National Institute on Drug Abuse show such deaths have tripled in the past 20 years. A report from the Centers for Disease Control and Prevention (CDC) released just last week showed more people died of drug overdose in the United States during 2014 than in any previous year on record, with increases in opioid overdose deaths the driving factor. That year, opioid overdose deaths, including deaths from opioid analgesics and heroin, increased by 14% over previous years.

The Medscape Opioid Use and Addiction Survey was completed by 1513 US clinicians between November 20 and December 8, 2015. The largest health professional group was physicians (n=832), including specialists in anesthesiology, emergency medicine, general practice/internal medicine/family practice/primary care, neurology, and psychiatry, followed by nurse practitioners (n=491).

Statistical significance across all clinicians was reported at a 95% confidence level with a margin of error of ±2.52%, using a point estimate (a statistic) of 50%, given a binomial distribution, the summary document notes.

The companion WebMD Opioid Use and Addiction Survey was completed by 1887 website visitors from November 18 to 25, 2015. The sample represents the WebMD.com online population with a margin of error of ±2.25% at a 95% confidence level, using a point estimate of 50%, given a binomial distribution.

Most health professionals surveyed (88%) reported that they prescribe opioids to their patients. The biggest patient pool for these prescriptions is for acute pain.

Health professionals report that they are concerned about misuse and abuse of these prescriptions. About two thirds (66%) believe patients are frequently taking more than prescribed, and more than half think patients frequently share pain medications or become addicted (55% and 54%, respectively).

About one in three health professionals said opioid use often leads to stronger drugs, such as morphine and heroin, and to prescription medications "falling into the wrong hands (e.g., children, teens)."

More than two thirds of health professionals (69%) said they prescribe fewer opioids now than in the past. This is reflected in the IMS Health data showing that prescriptions fell from a high of 219 million in 2011 to 207 million in 2013.

Opioid Alternatives

Many health professionals report suggesting opioid alternatives to their patients. For acute pain, 90% prescribe or recommend over-the-counter pain medications; 68%, a topical analgesic; 46%, an antidepressant; and 40%, a nerve block. The respective percentages for chronic pain are 76%, 61%, 69%, and 54%.

Asked what efforts they feel could be most effective in curbing opioid abuse, misuse, and diversion, 35% of health professionals cited improved prescription-monitoring programs; 33%, increased patient education; and 26%, increased clinician education. Only 6% thought increased availability of drug take-back programs would be most effective.

Consumers, too, believe opioid misuse and abuse are common. Almost half (46%) agreed these drugs are frequently used in ways other than prescribed and that addiction occurs frequently (46%).

Interestingly, while 42% of consumers said they believe opioid sharing occurs frequently, only 2% said they themselves share opioids.

Of the patients who have taken an opioid in the past 3 years, 43% took it for acute pain and 28% for noncancer chronic pain. Main sources for these opioids include the following: one doctor (75%), multiple doctors (8%), and after a hospital or emergency department visit (27%).

A "Loaded Gun"

Medscape Medical News asked several pain medicine experts to comment on the survey findings. Many agreed that the issues the surveys highlighted are common knowledge in the pain community.

But some experts identified inconsistencies. Lynn Webster, MD, vice president, scientific affairs, PRA Health Sciences, pointed out that what he found "most striking" was that nearly all the patients reported having tried relieving their pain with nonopioids before using an opioid, which is exactly what is being proposed in guidelines from the CDC.

"This challenges the common belief that opioids are too often prescribed as a first-line therapy," said Dr Webster. "In fact, they were reserved for when nonopioid therapy failed to provide relief. If we can generalize this finding, then the guidelines assuming opioids are prescribed too soon may be baseless and that we need to look to other means to curb the opioid crisis."

Jeffrey Fudin, PharmD, founder and chair, Professionals for Rational Opioid Monitoring & PharmacoTherapy (PROMPT), adjunct associate professor, Western New England University College of Pharmacy, and adjunct assistant professor of pharmacy practice, University of Connecticut School of Pharmacy, Storrs, also noted the survey indicated that opioids might not be used as initial therapy.

"[O]pioids in fact are not being used first line as media muckrakers might have us otherwise believe," said Dr Fudin. It's "reassuring," he added, to learn that so many patients try alternative therapies first.

Pressured Practitioners

The health professional survey may not have captured the pressures that general practitioners are under when treating pain patients, says Bill McCarberg, MD, a primary care provider in Escondido, California, and president, American Academy of Pain Medicine (AAPM).

He explained that busy general practitioners, who are often the ones treating pain patients, are expected to find quick and successful pain relief for patients worried about missing work. When getting behind with waiting patients, "we just give them the easiest option, which is a prescription for an opioid; that's kind of our default and that's not what we should be doing," said Dr McCarberg.

He used the example of a patient who has not responded to multiple treatments and then tried her mother's Vicodin, which was the only treatment that worked. "So now you're kind of stuck; are you not going to give her Vicodin as that's the thing that worked for her?"

At the same time, though, Dr McCarberg is noticing a different trend emerging in his practice — more patients, some with a history of alcohol abuse, worried about becoming addicted to an opioid.

"There is a switch in that patients are less likely to want or demand this medication; I'm hearing that more than in the past," he said.

The survey results also seem to suggest that while patients do try nonopioid pain relievers, they may give up too easily. "It almost looks like people try one thing and if it doesn't do the job sufficiently, they drop it," said Daniel B. Carr, MD, chair, education committee and president elect, AAPM, and professor of public health and community medicine and program director, pain, research education and policy, Tufts University School of Medicine, Boston, Massachusetts.

Using as an example a patient whose pain is rated as 6 of 10, Dr Carr said he first discusses a realistic goal — a score not of 0 but possibly 2 — and then a way to decrease the pain by 4 points to reach that goal. While one approach may get the pain level down only a point or two, combining strategies (eg, physical therapy with a nonsteroidal anti-inflammatory drug [NSAID]) might bring it down to a tolerable level. Dr Carr called this a "multimodal" approach to analgesia.

On a typical pain scale, a score of 3 or less is considered to indicate mild pain, which is least likely to interfere with daily activities; 4 to 6 represents moderate pain; and 7 to 10 represents severe pain.

Dr Carr pointed out that great strides are being made in providing nonopioid and nondrug approaches to pain management. For example, he said, there are some "very promising" device-based treatments, including transcranial magnetic therapy.

"Devices are improving every day, and manufacturers are developing new classes of drugs" that target pathways different from those of traditional nonsteroidals and opioids, said Dr Carr.

The pain experts who agreed to comment also focused on the 42% of consumers who admitted to storing unused medications for future use. "It appears that most of this medication is not in a secured location," said Dr Webster. "This is like having a loaded gun in a home."

It appears that most of this medication is not in a secured location. This is like having a loaded gun in a home. Dr Lynn Webster

Dr Fudin said he "wasn't at all surprised" that so many consumer respondents store unused pills. "I'm surprised it was so low. I suspect these same consumers keep prescription NSAIDs or antibiotics for sharing or future use as well.  Clearly, this is a reason for shorter supplies and more frequent follow-ups."

Dr McCarberg, too, felt that the 42% was not representative of the true number of patients storing narcotics. "It's very difficult to get a patient to not store their pills when their pain problem goes away," he said. Many want a "safeguard" should their pain problem recur, he said, adding that it's difficult to get a prescription for an opioid, with patients often having to sit for hours in an emergency department.

Mixed Message

The survey finding that more opioids are being prescribed for acute pain has "a mixed message," according to Dr Fudin. This is "presumably acceptable" if these prescriptions are for short supplies without renewals, with an expected reasonable healing time, he said. "My fear is that this is not the case."

"In fact," he continued, "unless there are comorbid medical conditions precluding anti-inflammatories, NSAIDs should always be used first line for dental procedures and minor connective tissue injuries with a preference towards etodolac or other COX-2 [cyclooxygenase]–selective NSAIDs if there is a bleeding risk to the injured area."

Dr Fudin said he fears that providers have become "quite impressionable" through media accounts and what he called "antiopioid zealots." He noted that in this survey, about 30% of health professionals said opioid use often leads to stronger drugs, such as morphine and heroin. "There is much more to the equation than this," he said.

Perhaps another part of the equation is what Dr Carr called the "well-documented undertreatment and underassessment" over the past 20 to 25 years of people experiencing all types of pain. Research shows that chronic low back pain is the major cause of chronic disability across North America and Europe.

Dr Fudin found it "particularly disheartening" that of the very same health professional survey respondents who believe prescribed opioids lead to heroin, only 26% said increased clinician education was needed. 

"If legitimate opioid prescriptions do lead to stronger drugs, doesn't it make sense that these providers need more education to properly stratify risk in the first place and learn to properly monitor after the fact? To say on the one hand that these drugs are an issue while 74% don't think they need more education is counterintuitive." 

Dr McCarberg pointed out how little pain-related education doctors get in medical school or in residency. Primary care doctors should "absolutely" get more education, he said, adding that he would have put education high on the survey's list of ways to help curb opioid abuse, misuse, and diversion. He also noted that urine drug testing wasn't on the list of options to curb abuse.

What was on the list — and was most commonly cited as the most effective way to address the opioid problem — was improving the effectiveness of prescription monitoring programs. According to Dr McCarberg, the District of Columbia and every state but Missouri has such a prescription monitoring program. The problem, he said, is that few general practitioners actually use these programs.

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