Physician assessments of drug seeking behavior: A mixed methods study

Abstract

BackgroundPain complaints are common, but clinicians are increasingly concerned about overuse of opioid pain medications. This may lead patients with actual pain to be stigmatized as “drug-seeking,” or attempting to obtain medications they do not require medically. We assessed whether patient requests for specific opioid pain medication would lead physicians to classify them as drug-seeking and change management decisions.Methods and findingsMixed-methods analysis of interviews with 192 office-based primary care physicians after viewing video vignettes depicting patients presenting with back pain. For each presentation physicians were randomly assigned to see either an active request for a specific medication or a more general request for help with pain. The main outcome was assignment by the physician of “drug-seeking” as a potential diagnosis among patients presenting with back pain. Additional outcomes included other actions the physician would take and whether the physician would prescribe the medication requested.A potential diagnosis of drug-seeking behavior was included by 21% of physicians seeing a specific request for oxycodone vs. 3% for a general request for help with back pain(p<0.001). In multivariable models an active request was most strongly associated with a physician-assigned diagnosis of drug-seeking behavior(OR 8.10; 95% CI 2.11–31.15;p = 0.002); other major patient and physician characteristics, including gender and race, did not have strong associations with drug-seeking diagnosis. Physicians described short courses of opioid medications as a strategy for managing patients with pain while avoiding opioid overuse.ConclusionsWhen patients make a specific request for opioid pain medication, physicians are far more likely to suspect that they are drug-seeking. Physician suspicion of drug-seeking behavior did not vary by patient characteristics, including gender and race. The strategies used to assess patients further varied widely. These findings indicate a need for the development of better clinical tools to support the evaluation and management of patients presenting with pain.

The use of experimental vignette studies to identify drivers of variations in the delivery of health care: a scoping review

“… USA Acute Physician Consultation style Ethnicity (black, white) Verbal and non-verbal communication between patient & physician Metastatic gastric and pancreatic cancer Physicians used similar verbal but different nonverbal communication behaviours with black and white patients. Fischer et al, 2017 [ 61 ] To test whether patient requests for specific opioid pain medication would lead physicians to classify them as drug-seeking and change management decisions USA Primary care Physician Prescription Ethnicity (black, white) Patient (drug seeking) behaviour Pain (sciatica) Physician suspicion of drug-seeking behaviour was much higher when patients requested opioid medication. Physician suspicion of drug-seeking behaviour did not vary by patient characteristics, including gender and race.…”

“…Six of the moderate and high quality studies sought to collect data in settings that replicated aspects of healthcare delivery, for example by collecting data in physicians’ offices during clinic times [ 61 , 66 , 68 ]. Such data collection was not always achieved as planned; Sheringham et al sought to conduct an online study in clinic settings between appointments, but due to limited clinic IT facilities many participants completed the study at home [ 72 ].…”

Evaluation of US Food and Drug Administration-recommended abuse-potential questions in chronic pain patients without history of recreational opioid use: results and plan for research

“…In a recent editorial, Gorfinkel et al suggested that chronic pain patients may be misdiagnosed because the characteristics of mismanaged pain may mimic the criteria of opioid-use disorder 14. The need to understand clearly the reasons behind “liking” an opioid and the desire to “take it again” seem of paramount importance in patient populations 15…”

Healthcare provider knowledge, beliefs, and attitudes regarding opioids for chronic non-cancer pain in North America prior to the emergence of COVID-19: A systematic review of qualitative research

“…Seven articles elucidated the impact of a long-standing patient–provider relationship on prescribing opioids among a sample of 195 providers (166 primary care, 4 nurse practitioners, 8 physician assistants, 8 internal medicine, 3 specialists, 2 osteopath, 2 pharmacists, 2 other). 34 , 39 , 40 , 42 , 44 , 50 , 52 Having a long-standing relationship with a patient increased willingness to engage in discussions surrounding opioid prescribing. Providers noted that knowing the patient well, knowing their background, having a well-rounded level of trust, and having a strong relationship with their patient increased their comfort level when prescribing opioids: “If you’re the family doctor or long-term psychiatrist or internist who’s known them [the patient] for 10 years and now they’ve developed a pain problem, you already have a bank of goodwill both ways.” 34 …”