Long-term opioid therapy, aberrant behaviors, and substance misuse: Comparison of patients treated by resident and attending physicians in a general medical clinic

Jessica L. Colburn, MD; Donald R. Jasinski, MD; Darius A. Rastegar, MD

doi:10.5055/jom.2012.0111

Authors

Jessica L. Colburn, MD
Donald R. Jasinski, MD
Darius A. Rastegar, MD

DOI:

https://doi.org/10.5055/jom.2012.0111

Keywords:

opioid-related disorders, graduate medical education

Abstract

Objective: To compare rates of opioid prescribing, aberrant behaviors, and indicators of substance misuse in patients prescribed long-term opioids by resident physicians or attending physicians in a general internal medicine practice.

Design: Medical records of 333 patients who were prescribed opioids for at least three consecutive months were reviewed. Aberrant behaviors over a 2-year period were documented, including reporting lost or stolen medications or receiving opioids from more than one provider. Indicators of substance misuse were also recorded, including positive urine drug testing for illicit substances, addiction treatment, overdose, and altering prescriptions.

Results: An estimated 13.6 percent of the patients followed by residents had been prescribed opioids for three or more months; this was significantly higher than the rate for attendings (5.9 percent, p < 0.001). Patients followed by residents were more likely to have reported lost or stolen prescriptions or medication (25.7 percent vs 12.2 percent, p = 0.03) or to have received opioids from another provider (17.8 percent vs 7.6 percent, p = 0.008); they were also more likely to exhibit an indicator of substance misuse (24.8 percent vs 7.6 percent, p < 0.001). However, in multivariate analyses, aberrant behaviors and indicators of substance misuse were not significantly associated with having a resident physician.

Conclusions: Resident physicians at our institution are following a disproportionate number of patients on long-term opioids, many of whom exhibit aberrant behaviors and indicators of substance misuse. This underscores a need for better resident training and supervision to provide effective and safe care for patients with chronic pain.

Author Biographies

Jessica L. Colburn, MD

Instructor, Johns Hopkins University School of Medicine, Baltimore, Maryland

Donald R. Jasinski, MD

Professor, Johns Hopkins Bayview Medical Center, Baltimore, Maryland

Darius A. Rastegar, MD

Assistant Professor, Johns Hopkins Bayview Medical Center, Baltimore, Maryland

References

Upshur CC, Luckmann RS, Savageau JA: Primary care provider concerns about management of chronic pain in community clinic populations. J Gen Intern Med. 2006; 21: 652-655.

Kerns RD, Otis J, Rosenberg R, et al.: Veterans’ reports of pain and associations with ratings of health, health-risk behaviors, affective distress, and use of the healthcare system. J Rehabil Res Dev. 2003; 40: 371-379.

Arnow BA, Hunkeler EM, Blasey CM, et al.: Comorbid depression, chronic pain, and disability in primary care. Psychosom Med. 2006; 68: 262-268.

McCarberg BH, Nicholson BD, Todd KH, et al.: The impact of pain on quality of life and the unmet needs of pain management: Results from pain sufferers and physicians participating in an Internet survey. Am J Ther. 2008; 15: 312-320.

Edlund MJ, Steffick D, Hudson T, et al.: Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic non-cancer pain. Pain. 2007; 129: 355-362.

Blake S, Ruel B, Seamark C, et al.: Experiences of patients requiring strong opioid drugs for chronic non-cancer pain: A patient-initiated study. Br J Gen Pract. 2007; 57: 101-108.

Becker N, Bondegaard Thomsen A, Olsen AK, et al.: Pain epidemiology and health related quality of life in chronic nonmalignant pain patients referred to a Danish multidisciplinary pain center. Pain. 1997; 73: 393-400.

Baune BT, Caniato RN, Gracia-Alcaraz MA, et al.: Combined effects of major depression, pain and somatic disorders on general functioning in the general adult population. Pain. 2008; 138: 310-317.

Joranson DE, Ryan KM, Gilson AM, et al.: Trends in medical use and abuse of opioid analgesics. JAMA. 2000; 283: 1710-1714.

Gilson AM, Ryan KM, Joranson DE, et al.: A reassessment of trends in the medical use and abuse of opioid analgesics and implications for diversion control: 1997-2002. J Pain Symptom Manage. 2004; 28: 176-188.

American Pain Society: Guideline for the Use of Chronic Opiate Therapy in Chronic Noncancer Pain: Evidence Review. Glenview, IL: American Pain Society, 2009.

Okie S: A flood of opioids, a rising tide of deaths [published correction appears in N Engl J Med. 2001; 364(4): 290]. N Engl J Med. 2010; 363(21): 1981-1985.

Martell BA, O’Connor PG, Kerns RD, et al.: Systematic review: Opioid treatment for chronic back pain: Prevalence, efficacy, and association with addiction. Ann Intern Med. 2007; 146: 116-127.

Furlan AD, Sandoval JA, Mailis-Gagnon A, et al.: Opioids for chronic noncancer pain: A meta-analysis of effectiveness and side effects. CMAJ. 2006; 174(11): 1589-1594.

Kalso E, Edwards JE, Moore RA, et al.: Opioids in chronic non-cancer pain: Systematic review of efficacy and safety. Pain. 2004; 112(3): 372-380.

Noble M, Tregear SJ, Treadwell JR, et al.: Long-term opioid therapy for chronic noncancer pain: A systematic review and meta-analysis of efficacy and safety. J Pain Symptom Manage. 2008; 35: 214-228.

Substance Abuse and Mental Health Services Administration: Results from the 2005 National Survey on Drug Use and Health: National Findings. NSDUH Series H-32, DHHS Publication No. SMA 07-4293. Rockville, MD: Office of Applied Studies, 2007.

Compton WM, Volkow ND: Major increases in opioid analgesic abuse in the United States: Concerns and strategies. Drug Alcohol Depend. 2006; 81: 103-107.

Dunn KM, Saunders KW, Rutter CM, et al.: Opioid prescriptions for chronic pain and overdose: A cohort study. Ann Intern Med. 2010; 152(2): 85-92.

Fleming MF, Davis J, Passik SD: Reported lifetime aberrant drug-taking behaviors are predictive of current substance use and mental health problems in primary care patients. Pain Med. 2008; 9: 1098-1106.

Passik S: Issues in long-term opioid therapy: Unmet needs, risks, and solutions. Mayo Clin Proc. 2009; 84(7): 593-601.

Chabal C, Miklavz E, Jacobson L, et al.: Prescription opiate abuse in chronic pain patients: Clinical criteria, incidence and predictors. Clin J Pain. 1997; 13: 150-155.

Chou R, Fanciullo GJ, Fine PG, et al.: Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009; 10: 113-130.

Dobscha SK, Corson K, Flores JA, et al.: Veterans affairs primary care clinicians’ attitudes toward chronic pain and correlates of opioid prescribing rates. Pain Med. 2008; 9: 564-571.

Potter M, Schafer S, Gonzalez-Mendez E, et al.: Opioids for chronic nonmalignant pain. Attitudes and practices of primary care physicians in the UCSF/Stanford Collaborative Research Network. University of California, San Francisco. J Fam Pract. 2001; 50: 145-151.

Morley-Forster PK, Clark AJ, Speechley M, et al.: Attitudes toward opioid use for chronic pain: A Canadian physician survey. Pain Res Manage. 2003; 9: 189-194.

Yanni LM, Weaver MF, Johnson BA, et al.: Management of chronic nonmalignant pain: A needs assessment in an internal medicine resident continuity clinic. J Opioid Manag. 2008; 4: 201-211.

Chen JT, Fagan MJ, Diaz JA, et al.: Is treating chronic pain torture? Internal medicine residents’ experience with patients with chronic nonmalignant pain. Teach Learn Med. 2007; 19: 101-105.

Barnett DR, Bass PF III, Griffith CH III, et al.: Determinants of resident satisfaction with patients in their continuity clinic. J Gen Intern Med. 2004; 19: 456-459.

Liebschutz JM, Saitz R, Weiss RD, et al.: Clinical factors associated with prescription drug use disorder in urban primary care patients with chronic pain. J Pain. 2010; 11: 1047-1055.

Fleming MF, Balousek SL, Klessig CL, et al.: Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain. 2007; 8: 573-582.

Reid MC, Engles-Horton LL, Weber MB, et al.: Use of opioid medications for chronic noncancer pain syndromes in primary care. J Gen Intern Med. 2002; 17(3): 173-179.

Krebs EE, Lurie JD, Fanciullo G, et al.: Predictors of long-term opioid use among patients with painful lumbar spine conditions. J Pain. 2010; 11: 44-52.

Edlund MJ, Martin BC, Devries A, et al.: Trends in use of opioids for chronic noncancer pain among individuals with mental health and substance use disorders: The TROUP study. Clin J Pain. 2010; 26: 1-8.

Michna E, Ross EL, Hynes WL, et al.: Predicting aberrant drug behavior in patients treated for chronic pain: Importance of abuse history. J Pain Symptom Manage. 2004; 28: 150-158.

Passik SD, Kirsh KL, Donaghy KB, et al.: Pain and aberrant drug-related behaviors in medically ill patients with and without histories of substance abuse. Clin J Pain. 2006; 22: 173-181.

Morasco BJ, Dobscha SK: Prescription medication misuse and substance use disorder in VA primary care patients with chronic pain. Gen Hosp Psychiatry. 2008; 30: 93-99.