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June 23, 2105

Survey: Many Doctors Misunderstand Key Facets of Opioid Abuse

Lack of understanding may lead to continued overprescribing of addictive prescription pain pills

Many primary care physicians – the top prescribers of prescription pain pills in the United States – don’t understand basic facts about how people may abuse the drugs or how addictive different formulations of the medications can be, new Johns Hopkins Bloomberg School of Public Health research suggests.

This lack of understanding may be contributing to the ongoing epidemic of prescription opioid abuse and addiction in the U.S.

Reporting online June 23 in the Clinical Journal of Pain, the researchers found that nearly half of the internists, family physicians and general practitioners surveyed incorrectly thought that abuse-deterrent pills – such as those formulated with physical barriers to prevent their being crushed and snorted or injected – were actually less addictive than their standard counterparts. In fact, the pills are equally addictive.

“Physicians and patients may mistakenly view these medicines as safe in one form and dangerous in another, but these products are addictive no matter how you take them,” says study leader G. Caleb Alexander, MD, MS, an associate professor in the Bloomberg School’s Department of Epidemiology and co-director of the school’s Center for Drug Safety and Effectiveness. “If doctors and patients fail to understand this, they may believe opioids are safer than is actually the case and prescribe them more readily than they should.”

He adds: “Opioids serve an important role in the treatment of some patients. However, our findings highlight the importance of patient and provider education regarding what abuse-deterrent products can and cannot do. When it comes to the opioid epidemic, we must be cautious about overreliance on technological fixes for what is first and foremost a problem of overprescribing.”

Another finding from the new research: One-third of the doctors erroneously said they believed that most prescription drug abuse is by means other than swallowing the pills as intended. Numerous studies have shown that the most common route by which drugs of abuse are administered is ingestion, followed by snorting and injection, with the percentage of those ingesting the drugs ranging from 64 percent to 97 percent, depending on the population studied. Certain medications are more likely than others to be snorted or injected.

Prescription drug abuse is the nation’s fastest growing drug problem, according to a report released by the White House in 2011. According to the U.S. Centers for Disease Control and Prevention, prescription 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. By 2009, prescription drugs surpassed motor vehicle crashes as a leading cause of unintentional death, with more people dying from prescription opioids than cocaine and heroin combined.

“Doctors continue to overestimate the effectiveness of prescription pain medications and underestimate their risks, and that’s why we are facing such a public health crisis,” Alexander says.

For the study, Alexander and his colleagues conducted a nationally representative survey of 1,000 primary care physicians between February and May 2014 examining their knowledge, attitudes and beliefs regarding prescription drug abuse. They focused not only on opioid abuse and diversion (the use of prescription drugs for recreational purposes), but also their support for clinical and regulatory interventions that may reduce opioid-related injuries and deaths.

The researchers found that all respondents believed that prescription drug abuse was at least a small problem in their communities, with more than half reporting it was a “big problem.” While there was disconnect in physicians’ understanding of some elements of abuse and addiction, the researchers found large support for a variety of measures that could reduce prescription opioid abuse.

Nearly nine out of 10 physicians said they “strongly supported” requiring patients to get opioids from a single prescriber and/or pharmacy, something that would cut down on the number of patients who go from doctor to doctor to get more pain pills than one doctor would prescribe.

Two-thirds of doctors strongly supported the use of patient contracts, where patients agree to properly use their pain medication and not give or sell it to others. More than one-half strongly supported the use of urine testing for chronic opioid users to make sure patients are taking their medication and not diverting it and are not taking drugs they are not prescribed.

Alexander says he is heartened by the numbers, but believes some physicians may be overstating their support for such measures, as they would be time-consuming to implement and, in the case of urine testing, are already recommended by some guidelines yet typically underused.

“Despite the high levels of support, there are many barriers to implementation and there may be reluctance to translate these changes into real-world practice,” he says. “But for the sake of making a dent in an epidemic of injuries and deaths, we have to find ways to make changes. Too many lives are at stake to stick with the status quo.”

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

The research was supported by the Robert Wood Johnson Public Health Law Research Program and the Lipitz Public Health Policy Award from the Johns Hopkins Bloomberg School of Public Health.

Alexander is Chair of the U.S. Food and Drug Administration’s Peripheral and Central Nervous System Advisory Committee; serves as a paid consultant to a mobile start-up designed to improve patient self-management of pain (PainNavigator); 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.

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 a co-plaintiff with the United States against Southwood Psychiatric Hospital, Pfizer and AstraZeneca. Kolodny is director of Physicians for Responsible Opioid Prescribing.

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Media contacts for the Johns Hopkins Bloomberg School of Public Health: Stephanie Desmon at 410-955-7619 or and Barbara Benham at 410-614-6029 or