Of all fifty states in the U.S., Utah has the fourth highest opioid overdose death rate. In a study presented at this year’s American Academy of Pain Medicine conference, one researcher compared data from Utah’s prescription monitoring program with information regarding prescription opioid deaths in that state. She did this to discover which physician specialties have the highest death-to-opioid prescription rates. (1)
The results were somewhat surprising. Though pain medicine specialists wrote only 1% of all opioids prescribed in the state, their patients accounted for 3% of the state’s overdose deaths. Family practice physicians prescribed the highest amounts of opioids in Utah, but had half the death rates of pain medicine specialists. Other specialties with high death-to-prescription rates were anesthesiologists, physiatrists (physical medicine and rehabilitation doctors), and physician extenders (nurse practitioners and physicians’ assistants).
Specialties with the lowest risk were internal medicine doctors, orthopedic surgeons, emergency room doctors, and dentists.
Of course, pain medicine specialists correctly responded to this data by reminding us that association doesn’t prove causation. The pain medicine specialists say they care for the most complicated of patients, referred when primary care physicians feel they need expert help.
This is an important point. You have to look at the population being treated.
I’m reminded of a similar example in my region. A few years ago, a local suburban community hospital claimed that patients admitted to their hospital had the lowest complication rates of any hospital in the area. They were correct, but it was because they referred very sick patients to a nearby urban tertiary care hospital. That hospital, caring for the sickest of the sick, had a high complication rate for their inpatients. In other words, the data was accurate but still misleading, due to the marked differences in the patient population treated by each hospital.
In the same way, pain medicine experts aren’t likely to be caring for uncomplicated, easily treated patients. The tough, complicated cases will be referred to them from primary care doctors.
Pain medicine specialists also point out that dentists and primary care doctors may be prescribing for many patients with acute, short-term pain. This type of patient is likely at less risk than patients with chronic pain from serious illnesses. The amount and strength of opioids that dentists and primary care doctors prescribe is likely to be lower than the amount and strength of opioids prescribed by pain specialists. And we know that the higher the dose of opioids prescribed, the more likely the patient is to suffer an overdose death.
The author of the study acknowledged the difficulty in interpreting the data, but also said she felt this information indicated a need for education for all the state’s physicians. Adding support for her recommendation is a report released last fall that describes the results of a survey of pain medicine specialists. (2) Only 70% of these specialists answered questions correctly about opioid abuse and the FDA’s new Risk Evaluation and Mitigation Strategies. Thirteen percent say they don’t assess their pain patients for risk of opioid misuse, which is now the recommended standard of care for all patients receiving long-term opioid prescriptions.
Getting back to the Utah study: It’s important to note that even in this state with a high overdose death rate, only .475% of all opioid prescriptions were associated with fatalities
1.Drug and Alcohol Dependence News, Feb. 28, 2012, citing Porucznik C, et al, “Physician specialty and opioid prescribing in the Utah controlled substance database 2005-2009 AAPM; Abstract 201.