Who Prescribes More Opioids for Pain Relief? Physicians or Physician Extenders?

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Photo of Dr. Michael Issac Ellenbogen, M.D.

Michael Ellenbogen, MD
Assistant Professor of Internal Medicine
Johns Hopkins School of Medicine 

What is the background for this study? What are the main findings?

Nurse practitioners (NPs) and physician assistants (PAs) are becoming an increasingly important and larger part of the healthcare workforce, especially in general internal medicine. To our knowledge, differences in opioid prescribing among generalist physicians, NPs, and PAs have not been evaluated. We aimed to learn if there are differences in opioid prescribing among generalist physicians, NPs, and PAs to Medicare beneficiaries.     

We performed a serial cross-sectional analysis of prescription claims from 2013 to 2016 using publicly available data from the Centers for Medicare and Medicaid Services. All generalist physicians, NPs, and PAs who provided more than ten total prescription claims between 2013 and 2016 were included. These prescribers were subsetted as practicing in a primary care, urgent care, or hospital-based setting.

We found that the overall volume and proportion of opioid prescribing is heavily right-skewed. The mean opioid prescription proportions (as a proportion of all prescription claims) for physicians in primary care, urgent care/walk-in clinics, and hospital medicine were 4.69, 6.72, and 6.66 relative to 7.10, 11.97, and 11.01 for PAs.  The adjusted total opioid claims across these four years for physicians was 660 (95% confidence interval: 660-661), for NPs was 755 

(95% CI: 753-757), and for PAs was 812 (95% CI: 811-814). 

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Nordic Countries Also See Rapid Increase in Opioid Prescriptions for Pain Relief

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PainRelief.com Interview with:
Ley (Ashley) Muller, PhD
University of Oslo

PainRelief.com:  What is the background for this study?  What are the main findings?

Response: The North American opioid crisis is clearly linked to the high availability of prescription opioids. In the Nordic countries of Denmark, Sweden, and Norway, the pharmaceutical industry is much more regulated, including bans on marketing to physicians, so the market isn’t flush with opioids. However, these countries have ageing populations with some of the highest rates of chronic non-cancer pain in the world, and over-prescription for this type of pain was one of the triggers of the North American crisis. 

This begs the question: how sure are we that strong pharmaceutical regulations alone can protect countries from prescription opioid problems?  

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Many Patients Prescribed Medical Marijuana for Pain Relief, Use the Cannabis for Recreational Use

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PainRelief.com Interview with:
Meghan Rabbitt Morean, Ph.D.
Assistant Professor of Psychology
Oberlin College
Adjunct Assistant Professor of Psychiatry
Department of Psychiatry 
Yale School of Medicine
New Haven, CT 04519

PainRelief.com:  What is the background for this study?

Response: Currently, medical marijuana is legal in 33 states and the District of Columbia and recreational marijuana is legal in 10 states and the District of Columbia (although it remains a Schedule I drug at the federal level).

Chronic pain is an approved condition for medical marijuana in all states in which medical marijuana is legal. However, there is concern that a sizeable percentage of medical marijuana patients also are using their medicine recreationally.

In the current study, we found that more than half (55.5%) of medical marijuana patients also reported using their medical marijuana for recreational purposes, which is similar to rates observed in a previous study.  

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National Trends in Prescription Opioid Risk Reduction Practices

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PainRelief.com Interview with:
Daniel P. Alford, MD, MPH
Professor of Medicine
Associate Dean, Continuing Medical Education
Director, Clinical Addiction Research and Education (CARE) Unit
Director, Safe and Competent Opioid Prescribing Education (SCOPE of Pain) Program
Boston University School of Medicine
Boston Medical Center, Boston MA 02118

PainRelief.com: What is the background for this study?

Response: Boston University School of Medicine’s Safe and Competent Opioid Prescribing Education (SCOPE of Pain) is the longest-running safer opioid prescribing educational program under the FDA’s opioid Risk Evaluation and Mitigation Strategy (REMS). 

This study analyzed clinicians’, who were registering to attend a SCOPE of Pain training, self-report of performing five opioid prescribing risk-mitigation practices with patients prescribed opioids for chronic pain including:

  1. Use of patient-prescriber agreements,

2) Informing patients about taking opioids exactly as prescribed,

3) Discussing safe opioid storage and disposal,

4) Discussing risks of opioid-associated respiratory depression and overdose, and

5) Monitoring for misuse including urine drug test and/or pill counts, prior to participating in the training.

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Mindfulness-Based Stress Reduction & Cognitive Behavioral Therapy for Chronic Pain Relief

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PainRelief.com Interview with:
Eve Ling-Khoo,MSc. OT Candidate, BSc. Hons
Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada

"Cognitive Therapy | Fox Valley Institute, Naperville IL (630) 718-0717" by Fox valley Institute is licensed under CC BY 2.0. To view a copy of this license, visit: https://creativecommons.org/licenses/by/2.0

PainRelief.com:  What is the background for this study?  What are the main findings?

  • 20% of adults worldwide suffer from chronic pain which impacts all facets of well-being.
  • Cognitive behavioral therapy (CBT) is the current gold standard for psychological intervention, but not everyone responds to it.
  • Mindfulness-based stress reduction (MBSR) is an alternative with the potential to improve the quality of life of patients with chronic pain.
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Variety of Pain Relief Medications Reduced Opioid Usage in Trauma Patients

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PainRelief.com Interview with:
Christine S. Cocanour, M.D., F.A.C.S., F.C.C.M.
Division of Trauma, Acute Care Surgery and Surgical Critical Care 
UC Davis Health

PainRelief.com:  What is the background for this study?

Response: Our critical care pharmacists (Duby, Hamrick and Lee) and surgeons (Cocanour, Beyer) wanted to decrease our use of opioids without compromising pain control in our trauma patients—especially those that were admitted to the ICU.  To help make more appropriate choices we put together an order set that was a multimodal approach to pain management. 

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Hypnosis for Pain Relief

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PainRelief.com Interview with:

Dr Trevor Thompson BSc Hons, MSc, PhD

Dr Trevor Thompson BSc Hons, MSc, PhD

Senior Lecturer, Faculty of Education and Health
University of Greenwich
London,United Kingdom

PainRelief .com:  What is the background for this study?  What are the main findings?

Response: Pretty much everyone now is aware of the opioid ‘crisis’. Opioid medications can offer highly effective pain relief for some, but also have addictive properties, side effects and provide unsatisfactory pain relief for many others. The Center for Disease Control and Prevention suggest that an estimated two million individuals in the US alone are addicted to prescription opioid analgesics, and this has been linked to over 17,000 overdose deaths and over $78 billion annual costs.

All of this has acted as a catalyst for renewed interest in non-pharmacological interventions for pain. Hypnosis is one such intervention and can be administered by a trained hypnotherapist or even as a simple 20-minute audio recording (usually in the form of relaxing imagery accompanied by suggestions of pain relief, e.g. ‘imagine being completely filled with sensation of relief’). The degree to which hypnosis is effective for reducing pain, however, is not entirely clear and exaggerated claims for its efficacy have generally created scepticism.  Clinical studies suggest hypnosis may be effective, but these data suffer from a number of limitations. We therefore analysed pooled data from controlled experimental studies that have used laboratory-induced pain (e.g. cold, heat, pressure etc), which can avoid some of the shortcomings of clinical data.

Meta-analysis of 85 studies consisting of 3632 participants supported the effectiveness of hypnosis and found that efficacy was strongly dependent upon hypnotic suggestibility. Compared to control conditions, pain ratings for hypnosis were 42% (p<.001) lower for individuals high in suggestibility and 29% (p<.001) lower for those with medium suggestibility.

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Neck and Back Pain More Common in Diabetes

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PainRelief.com Interview with:

Manuela L. Ferreira PhD
Institute of Bone and Joint Research
The Kolling Institute, Sydney Medical School

Paulo H. Ferreira PhD
Musculoskeletal Health Research Group
Faculty of Health Sciences
University of Sydney, Sydney, NSW, Australia

PainRelief.com:  What is the background for this study?  What are the main findings?

Response: One in four Australians experience back pain or neck pain. Diabetes is also a worldwide prevalent condition, and currently affects over 382 million people. These two diseases often co-exist and have very similar underlying mechanisms, such as obesity and physical inactivity. We were unsure whether having one condition would lead to developing the other, however.

We have found 11 studies published to date, and assessing the relation between back or neck pain and diabetes. The studies included over 165,000 participants published in the USA, Canada, Finland, Denmark, Iran and Spain.

When we pooled the results of these studies together, we observed that people with type 2 diabetes are 35% more likely to also have low back pain (compared to people without diabetes). The risk of having severe back pain symptoms in people with type 2 diabetes is 63% higher and the risk of having severe neck pain is almost 30% higher, than in people with no diabetes.  We could not identify, however, whether type 2 diabetes can lead to back or neck pain, and it is possible that the two conditions are associated via other underlying mechanisms such as obesity and physical inactivity.

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Opioid-Induced Constipation

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Chronic Pain Patients: Opioid Induced Constipation a Serious Concern After Surgery

PainRelief.com Interview with:

Jonathan Jahr, MD, DABA, FASA

Dr. Jonathan Jahr is an anesthesiologist in Los Angeles, California and is affiliated with multiple hospitals in the area, including UCLA Medical Center and UCLA Medical Center-Santa Monica. He received his medical degree from New York Medical College and has been in practice for more than 20 years.

Dr-Jonathan-Jahr

PainRelief.com:  What is the background for this study?  Why is it important?

Response: I have worked in the hospital setting for the past 25 years and have conducted multiple studies on different opioid and non-opioid strategies for managing both chronic and acute pain. I also co-edited a textbook entitled Essence of Analgesia and Analgesics. My background and the research I’ve done sets the stage for newer pain management protocols that can provide patients with significant pain relief, and improved satisfaction and outcomes due to fewer or avoided opioid related side effects (ORADS) such as opioid-induced constipation (OIC).

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EXPAREL TAP Block Provides Pain Relief For Cesarean Delivery With Less Opioids

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PainRelief.com Interview with:

B. Wycke Baker, MD
Chief of Service, Anesthesiology at Texas Children’s Pavilion for Women
Clinical Professor of Anesthesiology, Obstetrics and Gynecology
Baylor College of Medicine 

pacira pharmaceuticals

PainRelief.com:  What is the background for this study?  What are the main findings?

Response: For this study, we reviewed the charts of 201 women who underwent cesarean deliveries and received a multimodal pain management protocol with or without a TAP block utilizing EXPAREL, a long-acting, non-opioid option to manage pain following surgery. A TAP block, or a transversus abdominis plane block, is a field block that numbs the nerves that supply the abdominal wall. The study included patients who underwent elective, unscheduled waiting list, or emergency cesarean delivery with combined spinal-epidural anesthesia and post-cesarean pain management at Texas Children’s Hospital Pavilion for Women between 2012 and 2015.

The findings revealed many positive outcomes for patients who received a TAP block utilizing EXPAREL compared to those who received multimodal pain control without a TAP block utilizing EXPAREL. For instance, patients who received EXPAREL TAP block showed a significant decrease in postsurgical pain as well as a significant decrease in opioid consumption. On average, patients who received EXPAREL TAP block had shorter time to discharge from PACU, shorter time to readiness for discharge to home, and shorter length of stay in hospital than those who did not receive EXPAREL TAP block.

Further, a significantly higher number of patients treated with EXPAREL TAP block (12%) compared to those without EXPAREL TAP block (3%) consumed no opioids after surgery. Fewer patients treated with EXPAREL TAP block (34%) compared to those without EXPAREL TAP block (50%) reported any adverse events following the delivery.

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