Characteristics of physicians who prescribe opioids for chronic pain: a meta-narrative systematic review

Figures & data

Figure 1 Preferred reporting items for systematic reviews and meta-analyses flow chart of the study selection process.

Note: Reproduced from Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535. Creative Commons license and disclaimer available from: http://creativecommons.org/licenses/by/4.0/legalcode “http://creativecommons.org/licenses/by/4.0/legalcode.¹⁸

Table 1 Study characteristics

					Physician factors				Patient factors		Practice environment
Author	Study design	Survey	Number of physician participants	Physician demographics	Attitudes about pain and opioids	Pain training and knowledge	Awareness of adverse events	Opioid management	Pain etiology and other conditions	Patient satisfaction	Regulatory scrutiny	Clinical resources	Study funding
Bhamb 2006^Citation48	Cross-sectional	4-page written survey	Total=335; completed study=248; completion rate=74%	Wisconsin physicians; 70% family medicine; 29% internal medicine; mean age 41 years with 68% between ages 30–49; male 49%		56% with pain training in medical school or residency 17% concerned about lack of knowledge on which opioid to prescribe	84% concerned about opioid abuse, 75% about addiction, 68% about side effects, 61% about tolerance, 32% about medication interaction	93% do not do UDS before starting opioids and 85% do not do UDS 1–2 per year on established patients	Majority more likely to prescribe opioids to a patient with terminal cancer than patients with low back pain			56% established a system to track opioid patients Opioid tracking system associated with 2.5 greater odds of UDS use More than 1/3 of practices had no general agreement among physicians and staff about prescribing opioids	National Institutes of Health
Breuer 2010^Citation41	Cross-sectional; full study included PCP, PP, acupuncture specialists, chiropractors	Postal survey	Total (PCP and PP) =2000; completed study=474 completion rate=24%	National sample; median age PP 46; median age PCP 50; PP 84% male; PCP 71% male; private practice >72%; PP rural 9%; PCP rural 21%	PCP less confident treating musculoskeletal and neuropathic pain	PP had more chronic pain CME hours (76 hrs) compared to PCP (10 hrs) 56% PCPs and 73% PP favor pain education for all PCPs For PCPs, correlation between CME hours and confidence treating MSK and neuropathic pain		PCPS and PPs treated similar proportion of patients with short-acting opioids and tramadol; PCPs used more NSAIDs, PP more long-acting opioids			Regulatory concerns influence opioid prescribing in 29% PCP and 16% PP		Cephalon, Inc. Endo Pharmaceuticals
Chen 2011^Citation49	Cross-sectional	Postal and email survey; 23 items	Total=1083; completed study=197; completion rate=18%	National sample; PCP 48%; pain medicine 54%; oncology-palliative care 20%; teaching hospital 67%; urban areas 91%; male 65%	66% consider opioids somewhat effective 15% considered opioids to be dose limited		Opioid abuse indicative of failed therapy (60%)	Abuse or diversion suspected then 53% obtain drug screen 69% consider opioid contract necessary; 65% believe it improves communication; 37% believe it is legally protective About 50% initiate opioids with a combination of short and long-acting medications 55% self-initiated opioid therapy, 33% continued opioid therapy initiated by another physician Indicators of effective opioid therapy: improved function 76%; lower pain 62% Indicators of failed opioid therapy: no pain reduction 84%; function not improved 67% 73% considered methadone unique and 62% prefer oxycodone	75% considered opioids for cancer-related pain and 54% for low back pain 62% avoid opioids for fibromyalgia and 49% for chronic headache				Partially supported by a grant from the National Institutes of Health
Donovan 2016^Citation30	Cross-sectional with repeated measures assessment	Internet survey; 25-item multiple choice (assessing knowledge) and 16-item 5-point Likert scale assessment at pre-, post-, and 6-months after educational module	Total=53; completed study=33; response rate 62%	Physician faculty at Univ. Pittsburgh; male 51%; mean years of practice 16	Following educational module: improved confidence in the ability to improve lives of chronic pain patients; improved comfort in discussing opioid discontinuation with patients	61% with previous training in prescribing opioids at the faculty level Knowledge-based test scores improved following educational module (75% to 90%) Completion of educational module associated with improved teaching of residents							Thomas H. Nimick, Jr. Competitive Research Fund of the University of Pittsburgh Medical Center Shadyside
Duensing 2010^Citation32	Cross-sectional; full study included physicians and patients	Internet survey; physician survey included 21 items answered using multiple choice and 5-point Likert scale;	Repeated email sampling to achieve total sample size of 275 physicians	National sample; male 86%; age 30–59 yrs 90%; mean years in practice 17 General practice 44%; pain medicine 27% Private practice 83%; hospital-based 12%	Comfortable prescribing opioids for long term pain 71% 97% responded that effectiveness of opioids for providing pain relief somewhat/very important		Abuse or diversion somewhat or very important 87% 78%-89% reported side effects of N/V, constipation, dizziness, drowsiness, drug interactions somewhat or very important					85% non-pain specialists feel comfortable working with pain specialists to manage pain patients 67% felt widespread managed care coverage was somewhat or very important factor when prescribing opioid	Ortho-McNeil Janssen Scientific Affairs
Franklin 2013^Citation33	Cross-sectional; study included physicians as well as non-physician providers	Internet survey; 39 items	Completed study=285; total number and response rate not reported	Physicians in Washington State; PCP 100%		79%-84% state “web-based” CME or advanced training in chronic pain treatment would be helpful 71% read or applied guideline	73% very concerned about overdose, addiction, dependence or diversion.	91% would find use of PDMP helpful			25% very concerned about regulatory scrutiny	78% responded telephone consultation with experts would be helpful 68% had policy, guidelines, or algorithms available in clinic 86% reported patient decision aids would be helpful	Centers for Disease Control and Prevention National Center for Injury Prevention and Control
Green 2001^Citation42	Cross-sectional	Postal survey; 110 items	Total=1553; completed study=368; adjusted response rate=26%	Licensed Michigan physicians ale 73%; mean age 45; White 80%; Asian 12%; Black 6%; Hispanic/Latin2% PCP 63%; specialists 37%	Generally, respondents were satisfied with the pain care they provide	10% reported previous pain education; younger physicians more likely to receive pain education. Majority reported confidence in knowledge about various pain treatments					Disagreement over whether there is too much regulatory scrutiny Concern that prescribing opioids would “attract a medical review”		Blue Cross Blue Shield Foundation of Michigan
Howell 2015^Citation50	Cross-sectional; full study included non-physician opioid prescribers	Postal and emailed survey; 23-items	19% and 24% response rate for MD and DO; actual numbers not reported	Physicians in Washington State	80–83% reported moderate to extreme competence treating chronic pain 42%-52% report moderate to extreme satisfaction treating chronic pain			19–37% always require biological sample for drug screen 76%-90% always document health history 32%-34% always require written agreement 58–62% always conduct review of patient course 57–66% always require prescriptions by single provider 29–38% always specify reasons for discontinuing drug therapy	68–81% always review patient history for substance abuse				Bureau of Justice Affairs (Washington State) American Nurses Association
Hwang 2016^Citation51	Cross-sectional	Postal and email survey; 45 items; “most” responses 4-point Likert scale	Total=1000; completed study=420; adjusted response rate=58%	National sample; mean age 50; male 55%; white 70%; Asian 19%; African American 11% family medicine or internists 95%			95% believe addictive potential of opioids responsible for some to a lot of opioid abuse	90% somewhat or strongly support urine drug testing 98% somewhat or strongly support opioid contracts 98% somewhat or strongly support getting opioids from one prescriber 88% somewhat or strongly support PDMP					Robert Wood Johnson Foundation Public Law Research Program Lipitz Public Bloomberg School of Public Health
Kraus 2015^Citation34	Cross-sectional	Internet survey; 11-items	Completed study=219; total number targeted and response rate not reported	National sample; PCP 37%; pain specialist 26%; other 37%				51% report opioid contracts clarify therapeutic goals, side effects and drug interactions 47% report opioid contracts represent a mutually agreed upon course of treatment					Medscape, LLC
Macerollo 2014^Citation35	Cross-sectional	Internet survey; 16 items answered using 4-point Likert scale	Total=1099; completed study=581; response rate=53%	National sample of academic family medicine physicians; male 58%; non-Hispanic white 84%	74% believe pain management is a high priority 19% found it satisfying to prescribe opioids for pain 88% somewhat/strongly confident and 76% somewhat/strongly comfortable in their prescribing of opioids for CNMP 74% believe opioids provide substantial pain relief 73% believe opioids improve function Physicians who were more comfortable and/or confident were significantly more satisfied in prescribing opioids to patients with chronic pain		54% believe many patients become addicted Concerns about compliance (64–73%) and overdose (65%) 65% concerned about lack of addiction treatment resources			62% concerned about disagreement with patients about opioids	32% believe regulations influence prescribing practices	53% concerned about lack of specialized pain clinics	Not reported
Nishimori 2006^Citation43	Cross-sectional	Postal survey; 23-items	Total=250; completed survey=147; response rate=59%	Massachusetts area physicians; PCP 56%; pain specialists 44%	Pain specialists with >20 patients receiving opioids rated opioid effectiveness higher			91%-96% believe that drug loss, prescription tampering, multiple prescribing physicians, functional deterioration, frequent ED visits, and non-pain use indicative of unsuccessful treatment 75%-87% believe that unsuccessful treatment indicated by aberrant toxicology screen, unemployment, use of other person’s medication, relationship deterioration, use of alcohol or illicit drugs, cognitive deterioration, no pain improvement, dose escalation, unwilling to try other treatments, frequent unscheduled clinic appts Aside from changes in pain control, increases or decreases in function most important outcome
Nwokeji 2007^Citation36	Cross-sectional	Internet survey; 20 items answered using 7-point Likert scale	Total=2750; completed survey=267; response rate=10%	Texas Academy of Family Physicians; male 63%; white 74%; urban or suburban 71%; mean years in practice 16.5	63% somewhat to extremely likely to prescribe controlled-release (CR) opioids to patients with moderate to severe CNMP Prescribing CR opioids somewhat to extremely likely to control pain (81%) and improve quality of life (80%) Physicians unwilling to prescribe continuous release opioids held stronger beliefs about occurrence of opioid abuse or addiction		Prescribing continuous release opioids somewhat to extremely likely to lead to addiction (51%)				Prescribing CR opioids somewhat to extremely likely to lead to regulatory scrutiny (78%) Physicians unwilling to prescribe continuous release opioids held stronger beliefs about regulatory scrutiny	Prescribing continuous release opioids somewhat to extremely likely lengthen office visit (65%)	Not reported
Ponte 2005^Citation44	Cross-sectional	Postal survey; 20 items answered using 5-point Likert scale	Total 537; completed survey=186; response rate=34.5%	West Virginia Chapter of American Academy of Family Physicians; male 77%; age 35–54 yrs 64%; mean yrs in practice 15.5; group or solo private practice 71%	80% anxious about prescribing high-dose opioids to chronic pain patients; however 80% not apprehensive to prescribe for patients with chronic malignant pain 85% frustrated with chronic pain patients 93% believe patients satisfied with their pain management	60% report that their formal medical training in pain management was inadequate Incorrect knowledge about transdermal fentanyl use in opioid-naïve patients (67%), treatment of respiratory depression (51%), treatment of constipation (46%)			92% do not prescribe to patients with substance abuse history		68% believe regulatory scrutiny affected prescribing practices	89% report managing chronic pain is time consuming	Not reported
Porucznik 2013^Citation37	Cross-sectional	Internet survey; Yes/No and free text responses	Total=85; completed survey=47; response rate=55%	University-based community clinic system in Utah; PCP 70% 77% of respondents prescribe opioids for CNMP	8% comfortable, 34% somewhat comfortable, 34% somewhat uncomfortable, 8% uncomfortable with prescribing opioids Majority report dissatisfaction treating patients with chronic pain (mean score 17 and median score 16 on 0 to 100 scale)	Reported previous training about opioids during medical school (39%), residency (70%), CME (72%) Mean of 5 hrs (median of 3 hrs) opioid CME past 2 yrs 54% reported inadequate training about opioids 39% familiar with Utah opioid guidelines 85% report need for additional addiction training	Behaviors predictive of abuse include lost medications (92%), early refills (87%), persistent requests (85%), modifying prescriptions (81%)	Prior to starting opioids check PDMP (77%), sign contract (72%), perform urine toxicology screen (47%), assess function (45%) Report always documenting opioid contracts (41%), pain scale (38%), function (4%), discuss risks and benefits (37%), trials of non-opioid drugs (61%)					Food and Drug Administration Centers for Disease Control and Prevention National Institutions of Health Utah Department of Health
Remster 2011^Citation45	Cross-sectional	Postal survey; 29 items answered Yes/No, multiple choice, 4- to 5-point Likert scale	Total=1719; completed survey=413; adjusted response rate 26%	Physicians in Ohio’s Appalachian counties; male 74%; mean age 51; mean years of practice 20; work with chronic pain patients daily 42%	Perceived barriers to chronic pain management: physician reluctance to prescribe opioids (71%),		Perceived barriers to chronic pain management: patient fear of addiction (40%), patient reluctance due to adverse effects (36%)	Perceived barriers to chronic pain management: lack of objective pain measurement (72%), inadequate pain assessment (59%)		Perceived barriers to chronic pain management: patient reluctance to make lifestyle changes (88%), Perceived barriers to chronic pain management: financial burden for patient (73%), lack of patient transportation (57%)	Perceived barriers to chronic pain management were federal and state regulations (53%)	Perceived barriers to chronic pain management: inadequate access to pain specialists (78%)	Ohio Univ. College of Osteopathic Medicine Department of Family Medicine Research and Scholarly Affairs Committee
Slevin 2011^Citation38	Cross-sectional	Internet survey; 11-items with majority questions using Yes/No responses	Total=2800; completed study 259; response rate=9%	Pennsylvania family physicians; PCP 87%; specialist 13%; urban 52%; rural 48%;		48% willing to complete 2 hr CME on transmucousal fentanyl product 31% would discontinue opioids if required to complete mandated transmucousal fentanyl education		64% use signed contracts 40% use urine drug testing 18% do “periodic” pill counts			22% would discontinue opioids if required to document ongoing monitoring including efficacy, safety, aberrant behavior
Turk 1994^Citation46	Cross-sectional	Postal survey; 12-items most answered using 7-point Likert scale	Total=6962; completed study=1912; completion rate=27.46%	National sample of primary care and specialty physicians; mean number years in practice 17 Physicians from Midwest least likely to prescribe opioids; rheumatologists more likely to prescribe		Majority did not receive adequate pain education in medical school or residency	Expressed concerns about side effects, addiction, tolerance, physical dependence	Physicians expressed concerns functional improvement			Concerns about regulatory pressure were mixed between the different medical specialties		Purdue Frederick Company
Turk 2014^Citation39	Cross-sectional	Internet survey; Clinicians Attitudes about Opioids Scale (CAOS); validated, 38 items answered using 0–10 scale.	Total not reported, completed study=1535, response rate 47%	National sample of primary care and specialty physicians; male 83%; age 45–60 53%; 15 to >19 yrs practice 54%; group practice 75%; PCP 42%		Being certified in Pain Medicine and satisfaction with education/training in pain management associated with greater likelihood of prescribing tamper resistant opioids	Concerns about misuse or abuse predictive of prescribing tamper resistant opioids						Not reported but 2 co-authors employed by Janssen Scientific Affairs
Wastanmo 2015^Citation31	Cross-sectional with repeated measures assessment	Paper survey; 18 items answered using 5-point Likert scale administered pre- and 2 yrs post opioid safety initiative	Total pre-safety initiative=46; completed pre- assessment=34; completion rate=74% Total post-safety initiative=48; completed post assessment=31; adjusted response rate=61%	Physicians working at the Minneapolis VA Hospital		Pre/Post safety initiative 32% and 29% reported to have adequate training in chronic pain care Majority able to calculate MED	Majority agreed >200 MED increased risk of overdose Pre/Post safety initiative the majority reported doses <200 MED improved patient safety, improved quality of life, and protect prescriber			Pre/Post safety initiative majority reported lowering opioid dose <200 MED would upset patients		100% acknowledged importance of having consistent standard for prescribing opioids
Wilson 2013^Citation40	Cross-sectional validation study; dataset from Turk 2014 and Turk 1994	Internet survey; development and validation study of the 18 item CAOS questionnaire	1535 involved in validation study, see Turk 2014	National sample; demographics see Turk 2014 No differences in beliefs/practices among different regions on the country	Strong agreement to avoid long-term opioids if possible More male vs females believed strongly about efficacy of opioids Age <45 vs age 45–60 less confident about efficacy of opioids Orthopedist indicated greatest concerns about long-term opioid use Higher volume of chronic pain associated with increased opioid prescribing, less concern about impediments, less concern about Schedule II vs III drugs, indicated adequate pain training	Strong disagreement that pain education was adequate	Strong agreement that patients take opioids for non-pain reasons Strong agreement that tolerance is an impediment to long-term efficacy						Janssen Scientific Affairs, LLC
Wolfert 2010^Citation47	Cross-sectional	Postal survey; 32-items	Total=600; completed study=216; response rate 36%	Licensed Wisconsin physicians; working full-time 74%		40% with poor knowledge about state/federal prescribing laws 38% aware of one clinical guideline for chronic pain 51% reported previous training in pain management; 25% reported no formal training 43% reported good to excellent knowledge about pain management	54% believed diversion was a moderate to severe problem 19% correctly identified addiction		10% believed that prescribing to patients with a history of substance abuse was an acceptable practice		59% reported no regulatory concerns about prescribing practices Strategies to avoid investigation included limiting refills, prescribe smaller quantities and dose, prescribe opioid in lower schedule	76% reported that media coverage about opioid abuse did not impact prescribing practices	Shapiro Summer Research Program at the Univ. of Wisconsin School of Medicine and Public Health Univ. of Wisconsin Paul P. Carbone Comprehensive Cancer Center

Abbreviations: UDS, urine drug screen; PP, pain physician; PCPs, primary care providers; CME, continuing medical education; PDMP, prescription drug monitoring programs; N/V, nausea/vomiting; MD, medical doctor; DO, doctor of osteopathy; MED, morphine equivalent dose; CNMP, chronic non-malignant pain.

Table 2 Quality assessment using the adapted Newcastle-Ottawa scale for cross-sectional studies

Author	Selection domain^a	Comparability domain^b	Outcome domain^c	Overall judgement about risk of bias
Bhamb 2006^Citation48	2	0	1	High risk
Breuer 2010^Citation41	3	0	1	High risk
Chen 2011^Citation49	2	0	0	High risk
Donovan 2016^Citation30	1	0	1	High risk
Duensing 2010^Citation32	2	0	2	High risk
Franklin 2013^Citation33	1	0	1	High risk
Green 2001^Citation42	2	0	1	High risk
Howell 2015^Citation50	1	0	2	High risk
Hwang 2016^Citation51	1	0	2	High risk
Kraus 2015^Citation34	1	0	1	High risk
Macerollo 2014^Citation35	3	0	1	High risk
Nishimori 2006^Citation43	1	0	1	High risk
Nwokeji 2007^Citation36	1	0	1	High risk
Ponte 2005^Citation44	2	0	1	High risk
Porucznik 2013^Citation37	1	0	1	High risk
Remster 2011^Citation45	2	0	1	High risk
Slevin 2011^Citation38	1	0	1	High risk
Turk 1994^Citation46	4	0	1	High risk
Turk 2014^Citation39	3	1	2	High risk
Westanmo 2015^Citation31 (d)	1	0	0	High risk
Wilson 2013^Citation40	4	0	2	High risk
Wolfert 2010^Citation47	3	0	1	High risk

Notes:^aSelection domain scores ranged from 0–4. One point assigned for each criteria: (1) representativeness of exposed cohort; (2) selection of non-exposed cohort; (3) ascertainment of exposure; (4) targeted outcome not present at baseline. ^bComparability domain scores ranged from 0–2. One point assigned for each criteria: (1) study controlled for age; (2) study controlled for any additional factor. ^cOutcome domain scores ranged from 0–3. One point assigned for each criteria: (1) assessment of outcome; (2) was follow-long enough for outcome to occur; (3) adequacy of follow-up of cohorts. ^dScore of provider perceptions survey only.

Figure 2 Factors associated with prescribing opioids for chronic pain (reported by >50% of physicians).

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