Access to Primary Care Clinics for Patients With Chronic Pain Receiving Opioids

Abstract

IMPORTANCE Opioid-prescribing policies and guidelines aimed at reducing inappropriate opioid prescribing may lead physicians to stop prescribing opioids. Patients may thus encounter difficulties finding primary care practitioners willing to care for them if they take opioids. OBJECTIVES To assess practitioner willingness to accept and continue prescribing opioids to new patients with pain and whether this willingness differs across payer types. DESIGN, SETTING, AND PARTICIPANTS This survey study used a simulated patient call audit method. A brief telephone survey was administered to all clinics followed by a call using a patient script simulating an adult patient with chronic pain who was taking long-term opioids. The patient had Medicaid or private insurance. Calls were made between June 22 and October 30, 2018, to 667 primary care clinics that served a general adult population in Michigan. Clinics that accepted both Medicaid and private insurance, took new patient appointments, and were successfully recontacted for the simulated call were eligible for the study. MAIN OUTCOMES AND MEASURES Prevalence of clinics' acceptance of new patients receiving prescription opioids overall and by clinic characteristics and insurance type. RESULTS Of the 194 eligible clinics, 94 (48.4%) were randomized according to insurance type to receive calls from research assistants posing as children of patients with Medicaid and 100 (51.5%) to receive calls from those with private insurance. Overall, 79 (40.7%) stated that their practitioners would not prescribe opioids to the simulated patient. Thirty-three clinics (17.0%) requested more information before making a decision. Compared with single-practitioner clinics, clinics with more than 3 practitioners were more likely (odds ratio [OR], 2.99; 95% CI, 1.48-6.04) to accept new patients currently taking opioids. No difference was found in access based on insurance status (OR, 0.92; 95% CI, 0.52-1.64) or whether the clinic offered medications for opioid use disorders (OR, 1.10; 95% CI, 0.45-2.69). CONCLUSIONS AND RELEVANCE The findings suggest that access to primary care may be reduced for patients taking prescription opioids, which could lead to unintended consequences, such as conversion to illicit substances or reduced management of other medical comorbidities.

Geopersonality of Preventable Death in the United States: Anger-Prone States and Opioid Deaths

“…It is notable that yearly state-level opioid prescribing rates were associated with fewer opioid overdose deaths in the final model, potentially reflecting the evolving nature of the opioid crisis in which illicit and synthetic opioids are being abused. 1,2 The current study suggests that regional variation in anger regulation is an important cultural backdrop for understanding why opioids are misused.…”

“…1 Surveys suggest that a number of clinicians do not accept new patients who use opioids in an effort to avoid patient risks and professional liability. 2 In contrast, palliative care clinicians specialize in treating painful conditions with complex etiologies that may require opioid therapies. Opioid misuse is common, and even when used as prescribed many patients develop symptoms of tolerance and withdrawal.…”

Nonconsensual Dose Reduction Mandates are Not Justified Clinically or Ethically: An Analysis

“…Sequential papers in 2019 showed: (a) that most discontinuation among high dose Medicaid patients in Vermont was rapid, and often followed by hospital care; 56 (b) that cessation was associated with increased risk of death from overdose in one health system, 57 and termination of care relationships in another; 58 (c) that upward and downward dose variations were associated with elevated overdose risk in Colorado; 59 (d) that physicians reduce doses rapidly in ways that exceed CDC Guidelines among one in four patients; 60 (e) that prescription opioid cessation among veterans was followed by elevated risk of death from both overdose and suicide, in analyses that controlled for a range of patient characteristics. 61 Finally, a Michigan study found that 41% of primary care physicians refuse to see patients already receiving opioids, 62 a situation that limits the opportunities to protect the same patients.…”

Real-time prescription monitoring: helping people at risk of harm

“… 13 Authors of a study of mortality after discontinuation of opioid therapy suggested that these deaths could reflect interruption of other medical care, loss of tolerance, or destabilisation of an underlying opioid use disorder. 14 Primary care is well-placed to manage substance use disorder, but without support many GPs are reluctant to take on new patients being treated with opioids 15 or to prescribe opioid substitution therapy. 16 They may indiscriminately discharge patients with problems identified by real-time prescription monitoring from their practice.…”