2010 Survey of State Medical Board Members Reflects Trends in 2019 Opiate Prescribing Guidelines

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https://www.jpsmjournal.com/article/S0885-3924(10)00401-X/fulltext

Text from this study has been edited to aid and benefit readers without a medical background.

In the United States, physicians’ practice is regulated at the state level, with medical board members distinguishing legitimate medical practice from unprofessional conduct. For this process to be effective, regulators should have knowledge and beliefs that conform to current standards of practice and medical understanding. Past research has demonstrated that some board members continue to view the prolonged prescribing of opioid analgesics to treat non-cancer pain as being unlawful or unacceptable medical practice, especially when the patient with pain has a history of substance abuse.

Since state medical boards are the primary arbitrators for regulating physician practice, what board members think weighs heavily in the decisions made when treating and prescribing for chronic non-cancer pain.

The beliefs and views from members in 2010 are listed below. It should be noted when reviewing the data; younger board members at the time had a tendency to favor fewer levels of control and regulation as opposed to older members, an important fact when looking at how regulatory efforts have evolved. Also important, despite research indicating lower than expected addiction rates from treating chronic pain with opiates, medical board members continued to believe that such treatment led to higher rates of addiction. This reinforces the belief that as of 2019 the war on prescription opiates is primarily an ideological war, not a war based in factual science and research.

 

Beliefs about opioid addiction and diversion

 

 

Opioid diversion is a state problem

 

 

 

No

7.9%

 

 

Yes

64.8%

 

 

Missing

2%

 

Definition of addiction

 

 

 

Physiological symptoms

13%

 

 

Compulsive use and physiological symptoms       

59.9%

 

 

Compulsive use only  

24.5%

 

Addiction is common

 

 

 

No

40.8%

 

 

Yes

44.4%

 

 

Don’t Know

12.3%

 

 

Missing

2.5%

Beliefs and knowledge about federal and state policy

 

 

Importance of board’s pain policy

 

 

 

Not very or somewhat important

24.6%

 

 

Very important          

75.1%

 

 

Missing

0.4%

 

Board policies useful to improve pain management

 

 

 

No

6.9%

 

 

Yes

77.6%

 

 

Don’t Know

13%

 

 

Missing

2.5%

 

Federal law limits Rx amount

 

 

 

No

42.2%

 

 

Yes

18.4%

 

 

Don’t Know

37.9%

 

 

Missing

1.4%

 

Lawful to Rx methadone

 

 

 

No

7.2%

 

 

Yes

70.8%

 

 

Don’t Know

19.5%

 

 

Missing

2.5%

Clinical beliefs about opioid prescribing

 

 

Opioid doses greater than that recommended by drug manufactures are excessive

 

 

 

No

65.%

 

 

Yes

31.8%

 

 

Missing

2.9%

 

Doubt legitimacy if patient receives Rx for more than 1 opioid

 

 

 

No

70.4%

 

 

Yes

26%

 

 

Missing

3.6%

Demographic characteristics

 

 

Age

 

 

 

Mean

56.9%

 

 

Standard deviation

9.4%

 

Pain management training

 

 

 

Poor

20.1%

 

 

Fair

42.9%

 

 

Good or Excellent

37.3%

 

Addiction training

 

 

 

Poor

39%

 

 

Fair

38.6%

 

 

Good or Excellent

22.4%

Beliefs about Opioid Addiction and Diversion

Most (91%) respondents reported that they believed diversion and abuse of prescription opioids were a problem in their state. Board members also were asked to estimate how common it is for a patient to develop addiction resulting from prolonged opioid treatment. Slightly less than half (46%) believed addiction was common when opioids are used for an extended period to relieve pain. However, board members demonstrated an inaccurate understanding of the current conceptualization of addiction. When asked to define addiction using a brief list of several common terms (i.e., “physical dependence,” “compulsive use despite harm,” and “tolerance”) or a combination of terms, only 25% correctly associated addiction solely with compulsive use despite harm. Another 13% considered addiction to be composed of only physical dependence, tolerance, or both.

Beliefs and Knowledge about Federal and State Policy

A majority of respondents (75%) considered it very important for a state medical board to have a policy (i.e., regulation, guideline, or policy statement) for licensees regarding pain management and controlled substances, whereas 19% viewed it as somewhat important. Not only did most respondents consider medical board policies related to pain management to be important, but 80% believed that such policies are useful in improving patients’ pain relief. Less than half of the respondents (43%) knew that federal law does not limit the amount of a Schedule II controlled substance that can be prescribed at one time. In addition, 27% either did not know or incorrectly thought that physicians could not legally prescribe methadone for chronic pain.

Clinical Beliefs about Opioid Prescribing

One-third of respondents considered opioid dosages greater than those recommended in the Physician’s Desk Reference (PDR) or Product Package Insert as probably excessive and cause for concern about the appropriateness of the prescription order. Twenty-seven percent would doubt the legitimacy of a physician issuing prescription orders for more than one opioid for a single patient.

Demographic Characteristics

Respondents’ mean age was 57 years (range, 37–82 years), and this variable had a statistically normal distribution. When focusing on questions asked only of physician board members, 37% considered their training in pain management as either good or excellent, whereas only 22% reported the same level of adequacy about their training in addiction.

Patients with Non-cancer Pain

Table 2 shows that, of the 12 variables analyzed in this model, seven were associated with statistically significant results, and the entire model yielded a pseudo-R2 value of 45% and suggests a sizable goodness of fit. Examination of the beta coefficients and ORs showed that board members who characterized addiction solely by physiological phenomena were about 12% more likely to view prolonged opioid prescribing as an unlawful or unacceptable medical practice (OR=0.118, 95% CI: 0.021, 0.649). Viewing addiction as a common occurrence when opioids are used for an extended period to treat pain served to multiply the odds of viewing prolonged prescribing as unlawful or unacceptable by about one-third (OR=0.305, 95% CI: 0.104, 0.889). Finally, an incorrect belief that federal law limits the amount of a Schedule II controlled substance that can be prescribed at one time, while controlling for the influence of all other factors, was enough to increase the likelihood of interpreting prolonged prescribing as an unlawful/unacceptable practice (OR=0.083, 95% CI: 0.023, 0.303).

Predictors of Attitudes about the Legality of Prolonged Opioid Prescribing for Patients With Chronic Non-cancer Pain

Results show that, of the 12 variables analyzed in this model, seven were associated with statistically significant results, and the entire model yielded a pseudo-R2 value of 45% and suggests a sizable goodness of fit. Examination of the beta coefficients and ORs showed that board members who characterized addiction solely by physiological phenomena were about 12% more likely to view prolonged opioid prescribing as an unlawful or unacceptable medical practice (OR=0.118, 95% CI: 0.021, 0.649). Viewing addiction as a common occurrence when opioids are used for an extended period to treat pain served to multiply the odds of viewing prolonged prescribing as unlawful or unacceptable by about one-third (OR=0.305, 95% CI: 0.104, 0.889). Finally, an incorrect belief that federal law limits the amount of a Schedule II controlled substance that can be prescribed at one time, while controlling for the influence of all other factors, was enough to increase the likelihood of interpreting prolonged prescribing as an unlawful/unacceptable practice (OR=0.083, 95% CI: 0.023, 0.303).

Alternatively, when board members considered it very important for a board to have either a regulation or a guideline/policy statement regarding pain management (including the prescribing of opioids for pain), or when believing that such policies are useful to improve the treatment of pain, they were significantly more likely to hold the attitude that prolonged prescribing was both lawful and acceptable medical practice (OR=3.502, 95% CI: 1.070, 11.458 and OR=9.151, 95% CI: 1.619, 51.725, respectively). Those board members who reported that they would not doubt the legitimacy if a physician issued prescriptions for more than one opioid for a single patient were greater than six times more likely to consider prolonged prescribing to be lawful and acceptable (OR=6.694, 95% CI: 2.340, 19.148). In addition, younger board members were associated with favorable views about the prolonged prescribing of opioids for non-cancer pain (OR=1.062, 95% CI: 1.003, 1.125). This was the only demographic characteristic that was significant for this model.

Patients with Non-cancer Pain and a History of Drug Abuse

Having patients with both pain and a history of substance abuse considerably changed the overall profile found by the analytical model. Only four of the 12 included variables showed some significant effect, and the degree of goodness of fit was reduced to 39%.

As with the non-cancer model, believing incorrectly that federal law limits the amount of Schedule II medications that can be prescribed was associated with an increased likelihood to consider prolonged prescribing as unlawful or unacceptable medical practice (OR=0.168, 95% CI: 0.043, 0.648). Again, board members who viewed policies adopted by medical boards to be useful in improving pain management were eleven times more likely to consider prolonged prescribing as lawful and acceptable practice (OR=11.300, 95% CI: 1.616, 79.015). However, in this model, defining addiction as a combination of both compulsive use and physiological characteristics, rather than by physiological factors alone, increased by 25% the odds of labeling prolonged prescribing as unlawful/unacceptable practice (OR=0.247, 95% CI: 0.079, 0.774). Also unique to this model, regulators who reported the adequacy of their pain management training as poor, compared to those who reported good or excellent training, were more likely to view prolonged prescribing as unlawful or unacceptable (OR=0.133, 95% CI: 0.028, 0.642).

Discussion

Previous research has found that there is a notable minority of individuals serving on state medical boards in the United States who do not recognize the medical and legal acceptability of the chronic use of opioids for non-cancer pain, especially when the patient has a history of substance abuse. These attitudes have persisted since we began surveying medical regulators in the early 1990s, although federal law and the Federation’s national model policies have never prohibited such prescribing practices. Moreover, the last two decades were characterized by propagation of new state medical regulatory policy, with 46 state boards being involved in a current total of 66 regulations, guidelines, or policy statements governing pain management, the appropriate use of controlled substances, or both; now, more than ever before, state medical boards have approved policies reassuring physicians that they are not subject to regulatory sanctions for prescribing opioids for pain relief if reasonable professional practice is maintained and there is adequate documentation to support the treatment decisions. Inconsistency between the positive messages found in regulatory policy and the attitudes held by some board members who may oversee disciplinary cases will contribute to practitioner uncertainty when making treatment decisions about patients with chronic non-cancer pain who have previously engaged in drug abuse behaviors. It is, therefore, important to identify the factors that help shape medical regulators’ attitudes about prescribing legality, which may reveal the foundation for feasible approaches for fostering further evolution of more positive attitudes.

Results from this study demonstrated that it is indeed possible to use survey data to begin to understand medical board members’ knowledge and beliefs that contribute to their attitudes about the legality of chronic opioid therapy for non-cancer pain conditions. Binomial logistic regression models computed the predictive significance for only 12 independent variables, which together reasonably explained these attitudes. Board members were more likely to have the attitude that prolonged opioid therapy for chronic non-cancer pain was not legal or medically acceptable when they believed that addiction was defined only by physiological phenomena, that addiction was a common consequence of prolonged prescribing, and that federal law placed limits on the amount of Schedule II medication prescriptions. Alternatively, when regulators were younger, they thought that board policies were very important and were useful to enhance pain relief practices; they would not doubt the legitimacy of a prescribing practice if more than one opioid was prescribed to a single patient, and they were considerably more confident about the legality of such practice. For patients having a history of substance abuse, viewing prolonged prescribing as unlawful or unacceptable was associated with beliefs that physiological symptoms were central to the behavioral construct of addiction, that federal law imposes restrictions on amount of Schedule II prescriptions, and having had inadequate training in pain management. Believing that board policies have a role in improving pain management was related to more positive attitudes about chronic opioid treatment.

Regulators’ self-perceptions about the quality of their addiction training, within the separate multivariate frameworks, were not significantly associated with the occurrence of negative attitudes about prescribing legality. Only three other variables demonstrated no predictive power in either model: beliefs that opioid diversion is a state problem, that it is lawful to prescribe methadone for pain relief, and that prescribing opioids in doses greater than PDR recommendations is excessive (although this variable approached statistical significance for patients with an abuse history). Although these factors were part of broader variable domains related to various aspects of clinical and policy beliefs, such findings are noteworthy because they indicate that, when controlling for the influence of all other variables, these factors are not important predictors for board members’ pertinent attitudes about this issue. It appears that these variables, while seeming conceptually relevant, may address particular clinical and policy issues that are peripheral to making interpretations and judgments regarding non-cancer pain treatment with opioids.

Perhaps not surprisingly, the complete set of independent variables better predicted attitudes about prescribing for non-cancer pain than it did for attitudes relating to a patient with non-cancer pain and an abuse history. Almost twice as many independent variables were shown to have a significant effect for the model examining patients with non-cancer pain than for patients with pain and a history of substance abuse. It is likely that attitudes toward patients representing a more complex clinical situation (i.e., treatment of chronic pain with a comorbidity) are informed by a broader array of information and beliefs than were denoted by the variable domains. Interestingly, although the perceived extent of pain management training influenced attitudes toward prescribing legality, reported level of addiction training was not predictive, even when substance abuse was a characteristic of the chronic pain experience. These results suggest that training about pain treatment, rather than formal addiction training, is more important when defining the legitimacy of a practice involving sustained prescribing, non-cancer pain, and an abuse history. A potential explanation could be that recent pain management training that focuses on the principles of safe and effective care of patients with chronic pain, including the use of opioids and other pharmacologic modalities, also offers information about addiction-related concepts that interface with pain treatment issues. For example, evidence of these converging topics can be found in the web-based continuing education program, entitled “Balancing Opioid Prescribing,” which is sponsored by the Dannemiller Memorial Educational Foundation. Unfortunately, a lack of detail about the specific training content to which respondents were referring prohibits more nuanced interpretations and warrants further inquiry about the associative relationships between the independent variables used in this study.

Despite the non-predictive nature of formal addiction training, it remains important to enhance knowledge about the current conceptualization of addiction, which in turn can influence the perceived prevalence of addiction resulting from pain treatment with opioids. Recent research suggests that the development of [addiction caused by treatment] is rather low when patients use opioids for pain relief; yet close to half of all board members believe it to be a common occurrence. In addition, many medical regulators, like other health care professionals, still characterize addiction only in physiological terms (i.e., physical dependence and tolerance). The resiliency of these beliefs is likely a byproduct of the initial conceptualization of addiction as occurring in any individual who takes an opioid, as evidenced by the development of physical dependence and the manifestation of a withdrawal syndrome on cessation. It was not until the late 1960s that a World Health Organization (WHO) expert committee determined compulsive use despite harm to be the central feature of addiction (then termed “drug dependence”). Current WHO nomenclature, and U.S. diagnostic classifications, have maintained the emphasis on the detrimental consequences of compulsive use and have continued to relegate physical symptomatology as a concomitant but nonessential element. Laws in many states, however, fail to make this important distinction when providing definitions of addiction-related terminology, stemming from a definition in federal statute created in 1970. This conflict between current diagnostic nomenclature and definitions contained in state law has the potential to create ambiguity for both practitioners and regulators. As clinicians must understand the critical differences among addiction, physical dependence, and tolerance to avoid treatment decisions informed by the mislabeling of patients as “addicts” solely because of the possibility of a withdrawal syndrome, incorrect beliefs about addiction held by regulators can influence determinations made about disciplinary cases. These study results substantiate the need to educate medical board members about current addiction nosology and its implications for pain management, including its prevalence in chronic opioid therapy.

There is a need for future research to examine additional variables, and combinations of such variables, that may be even more predictive of attitudes about the legality of prescribing opioids for chronic non-cancer pain. Unfortunately, there is scant literature suggesting the identification of other viable ecological factors related to such attitudes. Perhaps subsequent surveys could include items that also seem related conceptually to the dependent variables used in this research, such as beliefs about the extent that physicians’ prescribing practices contribute to the societal burden of opioid abuse and diversion, the perceived effectiveness of opioid prescribing at producing sufficient pain relief or improved physical function, or the knowledge of other prescription requirements contained in federal law. Additional demographic variables could relate to whether the regulators themselves prescribe Schedule II opioids, treat patients with non-cancer pain, or treat patients with pain and comorbidities such as addiction (which are activities relevant only to board members who are physicians or perhaps other health care professionals), and their years of service on the board. Inclusion of these suggested characteristics within a multivariate statistical model, which allows for the control of the effects of all other variables, could result in more elaborately detailed and explanatory profiles of regulators’ attitudes. More complex and comprehensive models containing a broader array of knowledge and belief factors are only possible, however, with a much larger sample size. A larger sample size is necessary when examining a greater number of independent variables in the regression models to preserve adequate power and to protect against Type I error.

 

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