Chronic Opioid Prescribing in Primary Care

Factors and Perspectives

Sebastian T. Tong, MD, MPH; Camille J. Hochheimer; E. Marshall Brooks, PhD; Roy T. Sabo, PhD; Vivian Jiang, MD; Teresa Day; Julia S. Rozman; Paulette Lail Kashiri, MPH; Alex H. Krist, MD, MPH


Ann Fam Med. 2019;17(3):200-206. 

In This Article

Abstract and Introduction


Background: Primary care clinicians write 45% of all opioid prescriptions in the United States, but little is known about the characteristics of patients who receive them and the clinicians who prescribe opioids in primary care settings. Our study aimed to describe the patient and clinician characteristics and clinicians' perspectives of chronic opioid prescribing in primary care.

Methods: Using a mixed methods approach, we completed an analysis of 2016 electronic health records from 21 primary care practices to identify patients who had received chronic opioids, which we defined as in receipt of an opioid prescription for at least 3 consecutive months. We compared those receiving chronic opioids with those not in terms of their demographics, prescribing clinician characteristics, and risk factors for opioid-related harms, as identified by the Centers for Disease Control and Prevention Guideline on Opioid Prescribing for Chronic Pain. We then interviewed 16 primary care clinicians about their perspectives on chronic opioid prescribing.

Results: Of 84,029 patients, 1.1% (902/84,929) received chronic opioid prescriptions. Characteristics associated with being prescribed chronic opioids include being female, being of black or African American race, and having risks for opioid-related harms, such as mental health diagnoses, substance use disorder, and concurrent benzodiazepine use. Clinicians report multiple difficulties in weaning patients from chronic opioids, including medical contraindications of nonopioid alternatives and difficulty justifying weaning by stable long-term patients.

Conclusion: Although patients prescribed opioids in primary care have higher risks of opioid-related harms, clinicians report multiple barriers in deprescribing chronic opioids. Future studies should examine strategies to mitigate these harms and engage patients in shared decision making about their chronic opioid use.


Drug overdose deaths involving opioids continue to rise in the United States, with 42,249 people fatally overdosing in 2016, a 27.9% increase from 2015.[1] Although illicit substances such as heroin and illicitly manufactured fentanyl contribute significantly to the problem, prescribed opioids are involved in approximately 40% of opioid overdose deaths.[2] The National Survey on Drug Use and Health estimated that 1.8 million people had a prescription pain reliever use disorder and 11.5 million misused prescription pain relievers in 2016.[3] An estimated 215 million opioid prescriptions were dispensed by retail pharmacies in 2016, reaching a rate of 66.5 dispensed opioid prescriptions per 100 persons in the United States.[4] Of these opioid prescriptions, 45% were written by primary care clinicians.[5,6]

Despite high rates of opioid prescribing, the majority of primary care clinicians receive little or no training during medical school and residency in prescribing opioids or managing substance use disorders.[7–9] As a result, few primary care clinicians feel prepared to screen for, diagnose, and treat prescription medication misuse.[10–14] In recent years, a growing number of resources have been released to assist clinicians with managing opioid prescribing.[15–18] In 2016, the Centers for Disease Control and Prevention (CDC) released its Guideline for Prescribing Opioids for Chronic Pain, which includes recommendations on assessing risk factors for opioid-related harms when prescribing opioids.[15] Despite these guidelines, there remains substantial variation in the practice of prescribing opioids.[19–21]

Although other studies have examined large-scale variations,[22–25] little is known about the patient- and clinician-specific factors associated with any opioid and chronic opioid prescribing in primary care. The reliance in these studies on claims data limited the examination of patient, clinician, and practice characteristics. This limitation could be overcome by the use of electronic health record (EHR) data to examine patient and clinician characteristics that could account for risky opioid prescribing. Linking clinicians' perspectives to EHR data on prescribing practices can demonstrate the complexities of chronic opioid prescribing in primary care practice.