Practices Among Primary Care Providers Prescribing Opioids for Chronic Non-Cancer Pain – Marin County, CA, 2015

BACKGROUND:  Although Marin County consistently ranks as the healthiest county in California, local drug overdose death rates are higher than most California counties.   In response to the epidemic of prescription drug related overdoses, an increasing number of healthcare organizations employ guidelines for the safe prescription of opioids for chronic non cancer pain (CNCP). Little is known about the impact of such guidelines on practice.  To address this gap in knowledge in Marin, a survey was developed to describe and understand opioid prescribing practices and beliefs, and presence of organizational prescribing guidelines among primary care providers treating CNCP with opioids.

METHODS:  Survey content was developed by expanding on similar surveys conducted by two health plans in Marin County.  The survey was disseminated via physician and nurse practitioner e-mail distribution lists, and responses were solicited from those who prescribed opioids to patients with CNCP.  The survey focused on prescribing comfort level, opioid misuse prevention practices and resources, knowledge of opioid risks, and presence of organizational prescribing guidelines. The overall proportion of responses to each question was calculated.  Fisher’s exact test was used to assess differences between providers whose organizations do or do not have guidelines.  An α=0.05 was used for all significance testing.

RESULTS:  We received 80 responses.  Among respondents, 7.5% reported feeling very comfortable prescribing opioids when treating CNCP patients, 68% reported referring one or more patients for opioid addiction in the past year, 80% reported wanting resources for non-pharmacological alternatives, and 68% reported that their organization had prescribing guidelines.  In comparison to respondents whose organizations did not have guidelines about prescribing practices, respondents whose organizations had guidelines were more often utilizing formal opioid agreements (p=0.03), random drug screenings (p=0.04), patient education tools regarding CNCP (p=0.008), and prescription monitoring program  reports (p<0.0001).  Respondents whose organizations had guidelines about opioid prescribing also reported feeling more knowledgeable about the adverse effects of long term opioid use (p=0.01), how to handle opioid escalation (p=0.006), and how to assess for the possibility of opioid induced hyperalgesia (p=0.03).

CONCLUSIONS: The presence of organizational guidelines was associated with better opioid misuse prevention practices and improved knowledge of opioid management.  Implementing prescribing guidelines for providers treating CNCP may improve their knowledge of the adverse effects of chronic opioid use, impact best practices for preventing opioid misuse, and equip them to better identify opioid misuse.