There is a major deficiency in opioid knowledge among primary prescribers that may be driving inappropriate prescription practices, a new study suggests. According to the results from a 20-question survey, test scores showed no significant improvement in understanding between medical students and attending physicians, and no group, either by position or department—including anesthesiology—received a passing score.
“These results demonstrated a fundamental lack of knowledge in opioid prescribing, regardless of specialty or level of training,” said Stephen F. Goldberg, MD, an anesthesiologist at Thomas Jefferson University Hospital in Philadelphia. “In addition to this, there’s a false sense of confidence that all providers have it in their ability to prescribe these medications. With the increased prevalence of opioid use and concomitant rise in adverse events [AEs], targeted education on all levels of training and all specialties is imperative.”
As Scripts Increase, So Do AEs
As Dr. Goldberg reported, opioid prescriptions for pain management have increased by over 300% in the past 11 years, coinciding with a proportional increase in opioid-related AEs, including catastrophic morbidity and mortality.
“A lot of these AEs can be linked to inappropriate prescription practices,” said Dr. Goldberg. “Primary prescribers, many of whom are non–pain specialists, may be unaware of the associated risks and FDA labeling criteria.”
Dr. Goldberg’s study, presented at the 2015 annual meeting of the American Society of Anesthesiologists (abstract A3214), assessed physicians within four different departments (anesthesia, surgery, obstetrics and gynecology, and internal and family medicine) across multiple levels of training (medical students, residents and attending physicians). In total, 78 physicians participated in the study.
The 20-question survey entailed three parts. In the first section, participants rated their comfort with the use of opioids on a scale of 1 to 5. They then answered questions that tested their bias and knowledge regarding opioids.
“We were looking at knowledge of short- and long-acting opioids, basic pharmacology, physiology and side effects of opioids, as well as knowledge of the FDA labeling criteria for these medications,” Dr. Goldberg explained.
After finishing the test, participants were asked to reassess their comfort level with opioid medications.
Across all groups and levels of training, the researchers observed prescribing patterns that were inconsistent with evidence-based medicine.
“A fair number of people were likely to prescribe a long-acting opioid as their initial choice of therapy,” said Dr. Goldberg. “A lot of people didn’t understand the pharmacology related to the opioids themselves or medication interactions. There was just an across-the-board lack of knowledge in this very important area.”
While test scores varied in terms of specialty—anesthesiology scored higher than all other specialties—when researchers examined the numbers based on level of training, no statistical differences were observed. In other words, the medical students scored statistically the same as the attending physicians on this test.
“This tells us that there is a major inadequacy in opioid education, which starts at the medical school level, continues through residency and then can be seen in attending physician practice,” Dr. Goldberg said.
Finally, Dr. Goldberg noted that no group, either by position or department, including anesthesiology, received a passing test score (70% or higher). Despite changes in FDA guidelines, only 14% of participants surveyed were familiar with Risk Evaluation and Mitigation Strategy (REMS) training for prescribers.
“Ultimately, we’d like to develop a hospital-wide educational module that should be required for all physicians to complete so they’re more informed,” Dr. Goldberg concluded.
The moderator of the session, Amaresh Vydyanathan, MD, an anesthesiologist at Montefiore Medical Center in New York City, said the study speaks to the need for more substantial education regarding opioids.
“What’s most concerning is that the physicians who are actually prescribing in the community seem to be less informed than those who are not,” said Dr. Vydyanathan. “Internists and primary care specialists are doing the best that they can, but unfortunately, they are not equipped or educated to deal with this population of patients. … Pain is not one of the areas that they concentrate on in their training, and then suddenly they are receiving a bunch of patients who are coming with pain and asking for medication.
“But this is why the FDA instituted REMS,” Dr. Vydyanathan concluded. “It will take time, but hopefully, maybe in five years, it will be a lot safer than where we are now.”