Study Finds Opioid Prescribing Varies Widely among Family Physicians

Research shows that a minority of family physicians prescribe the majority of opioids to patient with chronic pain.

According to a news release from St. Michael’s Hospital in Toronto, Canada, researchers studying the opioid prescribing habits of family physicians in Ontario, Canada, found that some physicians prescribe oxycodone and other opioids more than 50 times as often as their colleagues. They also found that these opioid high-prescribers have a disproportionate number of patients who die opioid-related deaths, calling into question whether these physicians are following safe opioid prescribing practices.

Irfan Dhalla, general internist at St. Michael’s Hospital and an adjunct scientist at the Institute for Clinical Evaluative Sciences (ICES), said that he and his fellow researchers “found that the 20% of family doctors who are frequent prescribers wrote 55 times as many prescriptions as the 20% of family doctors who prescribe opioids the least.”

The study results were published in the March issue of Canadian Family Physician. For the study, Dhalla and colleagues performed a population-based cross-sectional analysis among patients in Ontario age 15 to 64 “who were eligible for prescription drug coverage under the Ontario Public Drug Program, a population in which the prevalence of opioid prescribing is high and in which high-dose prescribing (eg, 200 mg/d of morphine or equivalent) is common.”

They categorized physicians into quintiles according to the rate of their opioid prescribing and “divided the number of opioid prescriptions dispensed to public drug plan beneficiaries by the number of public drug plan beneficiaries treated by each physician.” Cause of death was based on information obtained from the coroner’s report.

The researchers found “marked variation in opioid prescribing,” with the average opioid-prescribing rate (931.5 per 1000 eligible patients) of upper-quintile prescribers dwarfing that of physicians in the lowest quintile (16.7 per 1000 eligible patients). The results also showed that “although there was an increase in the opioid-prescribing rate between each quintile, the largest increase—a 4.5-fold increase in prescribing rates—was evident between the top 2 quintiles.” Male sex and greater number of years of practice were associated with more frequent opioid prescribing.

In their discussion of these results, the authors noted that “Previous research has demonstrated temporal, geographic, and dose-related associations between opioid prescribing and mortality. Our findings illustrate an association between prescribing volume at the level of the individual physician and opioid-related mortality. Therefore, several lines of evidence suggest that increased opioid prescribing is associated with increased opioid-related mortality. Although the causal mechanism is likely to be complex, one important factor might simply be that more patients are placed at risk when more opioid prescriptions are written.”

Because opioid-related deaths appear to be concentrated among patients whose opioids are prescribed by a minority of physicians, the authors suggested that “targeting high-volume prescribers, perhaps through ‘academic detailing’ or focused regulatory intervention (eg, registration, audit, and monitoring for adherence to guidelines) might therefore help to reduce opioid-related mortality.”

HCPLive wants to know:

Do these results reflect your experience? Are the majority of prescriptions for opioid medications written by a comparatively small number of physicians?

Are family physicians and general practitioners sufficiently aware of the risks associated with prescribing opioids for chronic noncancer pain? Are more awareness and educational efforts needed?

Do you agree with the authors’ suggestion that “focused regulatory intervention” such as “registration, audit, and monitoring” or other rigorous requirements would be effective in reducing deaths from opioid misuse?

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