Opioid dose risk, clinician and patient characteristics, and adherence to opioid prescribing recommendations in chronic non-cancer pain





clinician adherence, long-term opioid therapy, chronic noncancer pain


Objective: This study aims to assess associations between morphine-equivalent daily dose (MEDD) of opioids, clinician and patient characteristics, and prescriber adherence to guidelines for long-term opioid therapy (LTOT) in chronic noncancer pain (CNCP) and to elucidate potential relationships associated with increased-risk opioid prescribing.

Design: Retrospective cross-sectional study.

Setting: Academic health system's 33 primary care clinics.

Patients: Adults (18 years old) prescribed LTOT (10 + outpatient prescriptions in the past year) for CNCP.

Main outcome measure(s): Electronic health record data on prescribed opioids (for MEDD), clinician/patient characteristics, and adherence rates to LTOT guideline-concordant recommendations.

Results: A total of 2,738 patients were eligible, 61.6 percent Lower, 15.7 percent Moderate, and 22.7 percent Higher Risk MEDD (<50, 50-89, and 90 mg/day, respectively). Higher MEDD correlated (p < 0.001) with Medicare insurance, current cigarette smoking, higher pain intensity and interference scores, and the presence of opioid use disorder diagnoses. Male clinicians more frequently prescribed (p < 0.001) and male patients were more likely to be prescribed (p < 0.001) higher MEDD compared to their female counterparts. Higher Risk MEDD was associated with higher coprescribed benzodiazepines (p = 0.015), lower depression screening (p = 0.048), urine drug testing (p = 0.003), comparable active treatment agreement (p = 0.189), opioid misuse risk screening (p = 0.619), and prescription drug monitoring checks (p = 0.203).

Conclusions: This study documented that higher MEDD was associated with risks of worse health outcomes without improved adherence to opioid prescribing guideline recommendations. Enhanced clinician awareness of factors associated with MEDD has the potential to mitigate LTOT risks and improve overall patient care.

Author Biographies

Christa Coleman, PsyD, MSCP

Assistant Professor, Departments of Psychiatry and Behavioral Health, and Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Hershey, Pennsylvania

Robert P. Lennon, MD, JD

Associate Professor, Department of Family and Community Medicine, Penn State College of Medicine, Hershey; Affiliate Faculty, Penn State Law, State College, Pennsylvania

James M. Robinson, PhD

Center for Health Systems Research and Analysis, University of Wisconsin-Madison, Madison, Wisconsin

Wen-Jan Tuan, DHA, MPH, MS

Assistant Professor, Department of Family and Community Medicine, and Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania

Nalini Sehgal, MD

Professor, Department of Orthopedic & Rehabilitation Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin

Aleksandra E. Zgierska, MD, PhD

Professor, Departments of Family and Community Medicine, Public Health Sciences, and Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Hershey, Pennsylvania


Centers for Disease Control and Prevention: Prescribing practices: Changes in opioid prescribing practices. Available at https://www.cdc.gov/drugoverdose/data/prescribing/prescribing-practices.html. Accessed March 3, 2021.

Kiang MV, Humphreys K, Cullen MR, et al.: Opioid prescribing patterns among medical clinicians in the United States, 2003-17: Retrospective, observational study. BMJ. 2020; l6968. DOI: 10.1136/bmj.l6968.

Bartoli A, Courtney K: What do the CDC guidelines mean for patients on long-term, high-dose opioids? Practical Pain Management. April 29, 2019. Available at https://www.practicalpainmanagement.com/resource-centers/opioid-monitoring-2nded/what-do-cdc-guidelines-mean-patients-long-term-high-dose. Accessed December 7, 2021.

Bialas P, Maier C, Klose P, et al.: Efficacy and harms of long-term opioid therapy in chronic non-cancer pain: Systematic review and meta-analysis of open label extension trials with a study duration ≥26 weeks. Eur J Pain. 2020; 24(2): 265-278. DOI: 10.1002/ejp.1496.

Voon P, Karamouzian M, Kerr T: Chronic pain and opioid misuse: A review of reviews. Subst Abuse Treat Prev Policy. 2017; 12(1): 36. DOI: 10.1186/s13011-017-0120-7.

US Department of Health and Human Services Centers for Disease Control and Prevention: Assessing benefits and harms of opioid therapy. Available at https://www.cdc.gov/drugoverdose/pdf/assessing_benefits_harms_of_opioid_therapy-a.pdf. Accessed December 7, 2021.

Dowell D, Haegerich T, Chou R: CDC guidelines for prescribing opioids for chronic pain—United States. MMWR Recomm Rep. 2016; 65(1): 1-49. DOI: 10.15585/mmwr.rr6501e1.

Busse JW, Craigie S, Juurlink DN, et al.: Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017; 189(18): E659-E666. DOI: 10.1503/cmaj.170363.

Hossain MA, Asamoah-Boaheng M, Badejo OA, et al.: Prescriber adherence to guidelines for chronic noncancer pain management with opioids: Systematic review and meta-analysis. Health Psychol. 2020; 39(5): 430-451. DOI: 10.1037/hea0000830.

Hubbard IJ, Harris D, Kilkenny MF, et al.: Adherence to clinical guidelines improves patient outcomes in Australian audit of stroke rehabilitation practice. Arch Phys Med Rehabil. 2012; 93(6): 965-971. DOI: 10.1016/j.apmr.2012.01.011.

Matthias MS, Parpart AL, Nyland KA, et al.: The patient–clinician relationship in chronic pain care: Clinicians' perspectives. Pain Med. 2010; 11(11): 1688-1697. DOI: 10.1111/j.1526-4637.2010.00980.x.

Matthias MS, Talib TL, Huffman MA: Managing chronic pain in an opioid crisis: What is the role of shared decision-making? Health Commun. 2020; 35(10): 1239-1247. DOI: 10.1080/10410236.2019.1625000.

Zgierska A, Rabago D, Miller M: Impact of patient satisfaction ratings on physicians and clinical care. Patient Prefer Adherence. 2014; 8: 437-446.

Zgierska A, Miller M, Rabago D: Patient satisfaction, prescription drug abuse, and potential unintended consequences. JAMA. 2012; 307(13): 1377-1378.

Coleman C, Lennon RP, Robinson JM, et al.: Sex disparities in opioid prescribing and patient outcomes. J Opioid Manag. 2022; 18(5): 435-445. DOI: 10.5055/jom.2022.0737.

Chen JH, Hom J, Richman I, et al.: Effect of opioid prescribing guidelines in primary care. Medicine (Baltimore). 2016; 95(35): e4760.

Mattson CL, Tanz LJ, Quinn K, et al.: Trends and geographic patterns in drug and synthetic opioid overdose deaths—United States, 2013–2019. MMWR Morb Mortal Wkly Rep. 2021; 70: 202-207. DOI: 10.15585/mmwr.mm7006a4.

Zgierska AE, Vidaver RM, Smith P, et al.: Enhancing system-wide implementation of opioid prescribing guidelines in primary care: Protocol for a stepped-wedge quality improvement project. BMC Health Serv Res. 2018; 18(1): 415. DOI: 10.1186/s12913-018-3227-2.

Deyo RA, Smith DH, Johnson ES, et al.: Opioids for back pain patients: Primary care prescribing patterns and use of services. J Am Board Fam Med. 2011; 24(6): 717-727.

US Department of Health and Human Services, Guidance Portal: Opioid oral morphine milligram equivalent (MME) conversion factors table for prescription drug coverage. Issued by: Centers for Medicare & Medicaid Services (CMS). January 1, 2020. Available at https://www.hhs.gov/guidance/document/opioid-oral-morphine-milligram-equivalent-mme-conversionfactors-0. Accessed April 30, 2021.

US Department of Health and Human Services: Pain management best practices inter-agency task force report: Updates, gaps, inconsistencies, and recommendations. 2019. Retrieved from US Department of Health and Human Services website. Available at https://www.hhs.gov/ash/advisory-committees/pain/reports/index.html. Accessed April 29, 2021.

Korff Jensen VM, Karoly MP: Assessing global pain severity by self-report in clinical and health services research. Spine. 2000; 25(24): 3140-3151.

US Department of Health and Human Services Data Resources: Analyzing opioid prescription data and oral morphine milligram equivalents (MME). Available at https://www.cdc.gov/drugoverdose/resources/data.html. Accessed April 29, 2021.

Manchikanti L, Abdi S, Atluri S, et al.: American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2–guidance. Pain Phys. 2012; 3S;15(3 Suppl): S67-S116.

Manchikanti L, Abdi S, Atluri S, et al.: American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part I–evidence assessment. Pain Phys. 2012; 3S;15(3 Suppl): S1-S66.

Kroenke KS, Williams JB: The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med. 2001; 16(9): 606-613.

Kroenke K, Spitzer R, Williams J: The patient health questionnaire-2: Validity of a two-item depression screener. Med Care. 2003; 41(11): 1284-1292.

Belgrade MJ, Schamber CD, Lindgren BR: The DIRE score: Predicting outcomes of opioid prescribing for chronic pain. J Pain Sep. 2006; 7(9): 671-681. DOI: 10.1016/j.jpain.2006.03.001.

Scherrer JF, Salas J, Lustman PJ, et al.: Change in opioid dose and change in depression in a longitudinal primary care patient cohort. Pain. 2015; 156(2): 348-355. DOI: 10.1097/01.j.pain.0000460316.58110.a0.

Cheatle MD, Falcone M, Dhingra L, et al.: Independent Association of Tobacco Use with opioid use disorder in patients of European ancestry with chronic non-cancer pain. Drug Alcohol Depend. 2020; 209: 107901. DOI: 10.1016/j.drugalcdep.2020.107901.

van Rijswijk SM, van Beek MHCT, Schoof GM, et al.: Iatrogenic opioid use disorder, chronic pain and psychiatric comorbidity: A systematic review. Gen Hosp Psychiatry. 2019; 59: 37-50. DOI: 10.1016/j.genhosppsych.2019.04.008.

Adams MH, Dobscha SK, Smith NX, et al.: Prevalence and correlates of low pain interference among patients with high pain intensity who are prescribed long-term opioid therapy. J Pain. 2018; 19(9): 1074-1081. DOI: 10.1016/j.jpain.2018.04.005.

Ólason M, Andrason RH, Jónsdóttir IH, et al.: Cognitive behavioral therapy for depression and anxiety in an interdisciplinary rehabilitation program for chronic pain: A randomized controlled trial with a 3-year follow-up. Int J Behav Med. 2018; 25: 55-66. DOI: 10.1007/s12529-017-9690-z.

US Food and Drug Administration: FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individual tapering. FDA Drug Safety Communication. 2019. Available at https://www.fda.gov/drugs/drug-safety-and-availability/fda-identifies-harm-reported-sudden-discontinuation-opioid-pain-medicines-and-requires-label-changes. Accessed December 7, 2021.

Witkiewitz K, Vowles KE: Alcohol and opioid use, co-use, and chronic pain in the context of the opioid epidemic: A critical review. Alcohol Clin Exp Res. 2018; 42(3): 478-488. DOI:


Centers for Disease Control and Prevention: CDC advises against misapplication of the guidelines for prescribing opioids for chronic pain. CDC Newsroom. April 24, 2019. Available at https://www.cdc.gov/media/releases/2019/s0424-advisesmis-application-guideline-prescribing-opioids.html. Accessed December 7, 2021.

Zgierska AE, Robinson JM, Lennon RP, et al.: Increasing system-wide implementation of opioid prescribing guidelines in primary care: Findings from a non-randomized stepped-wedge quality improvement project. BMC Fam Pract. 2020; 21(1): 245. DOI: 10.1186/s12875-020-01320-9.



How to Cite

Coleman, C., R. P. Lennon, J. M. Robinson, W.-J. Tuan, N. Sehgal, and A. E. Zgierska. “Opioid Dose Risk, Clinician and Patient Characteristics, and Adherence to Opioid Prescribing Recommendations in Chronic Non-Cancer Pain”. Journal of Opioid Management, vol. 19, no. 5, Nov. 2023, pp. 413-22, doi:10.5055/jom.0815.