Abstract

Objective. Opioid analgesics are the drugs of choice for the treatment of moderate to severe acute and cancer pain. Although their role in the management of chronic pain not related to cancer is controversial, there is increasing evidence for their benefit in certain patient populations.

Design. A 32-item survey to assess Wisconsin physicians' knowledge, beliefs, and attitudes toward opioid analgesic use was mailed to 600 randomly selected licensed physicians, resulting in a 36% response rate.

Results. Half of the respondents considered diversion a moderate or severe problem in Wisconsin. A majority considered addiction to be a combination of physiological and behavioral characteristics, rather than defining it solely as a behavioral syndrome. Most physicians felt it lawful and acceptable medical practice to prescribe opioids for chronic cancer pain, but only half held this view if the pain was not related to cancer. Fewer physicians considered such prescribing as lawful and generally accepted medical practice if the patient had a history of substance abuse. About two-thirds of physicians were not concerned about being investigated for their opioid prescribing practices, but some admitted that fear of investigation led them to lower the dose prescribed, limit the number of refills, or prescribe a Schedule III or IV rather than a Schedule II opioid.

Conclusion. Wisconsin physicians who responded to this survey held many misconceptions about the prescribing of opioids. Such views, coupled with a lack of knowledge about laws and regulations governing the prescribing of controlled substances, may result in inadequate prescribing of opioids with resultant inadequate management of pain.

Introduction

Opioid analgesics are essential for the management of acute and cancer pain [1–4] and may be important for the treatment of chronic noncancer pain in certain populations [5–8], although their role in the management of chronic pain not related to cancer remains controversial [9–11]. However, physicians hold many misconceptions about the use and risks associated with the use of opioid analgesics, as well as the policies that govern their use [12–16]. They are concerned that their prescribing for legitimate medical purposes can unintentionally contribute to illicit use and create addiction in their patients [17]. Although addiction, tolerance, and physical dependence are distinct phenomena with separate neurophysiological mechanisms [18], healthcare professionals often view these conditions as synonymous. If practitioners' diagnosis of “addiction” is based solely on the presence of physical dependence (as evidenced by withdrawal when the patient ceases opioid use), they will significantly overestimate the incidence of addiction when patients are treated with opioids. Physicians also are worried that their controlled substances prescribing practices will be investigated by state licensing boards, the U.S. Drug Enforcement Administration (DEA), or even by law enforcement [19–22]. Such misperceptions can contribute to decreased prescribing and inadequate treatment of pain, especially when a patient's pain is severe and requires Schedule II opioids (e.g., fentanyl, morphine, and oxycodone) [23]. A physician's clinical knowledge, beliefs, and attitudes help shape their prescribing practices and treatment decisions [15,24,25].

It is likely that apprehension about the medical use of opioid analgesics has been exacerbated in recent years by frequent national and state media reports about the diversion and abuse of opioids, which often fail to recognize that these drugs have legitimate medical purposes and are essential for relieving moderate to severe pain. An implicit, if not stated, message from these media reports is that physicians' inappropriate prescribing practices are responsible for the increased abuse and diversion of prescription opioid medications, regardless of the lack of direct evidence to support this assertion. In fact, there is little indication as to the primary source of diversion either nationally or in Wisconsin. Attention only to the abuse liability of opioids stigmatizes these medications and the practitioners who prescribe them, which may further contribute to under-treatment and, ultimately, to inadequate patient pain care [26].

Weissman and colleague's 1991 survey of Wisconsin physicians showed they had poor knowledge of controlled substances regulations and that their perceived risk of regulatory scrutiny affected their prescribing practices [27]. Findings from this study pointed to the need to address these regulatory concerns and to educate practitioners about what constitutes the safe and effective treatment of pain with opioids. Since then there have been major collaborative efforts among members of the pain community and state government agencies in Wisconsin to improve the clinical and regulatory climates as well as to increase physicians' knowledge of pain management in general and the use of opioids in particular [28–31]. In addition, in 2007 the Wisconsin Medical Examining Board, the state agency that licenses and disciplines physicians, issued a formal policy making pain relief an expectation of patient care.

Given the numerous pain-related professional and regulatory developments in Wisconsin since the early 1990s, we attempted to determine the current knowledge, beliefs, and attitudes, as well as reported prescribing practices, of physicians in the state. A survey was used to assess Wisconsin physicians' current knowledge of controlled substances regulations, as well as their use of and beliefs about these drugs. The questionnaire was designed to collect information related to a number of domains: 1) understanding of prescription medication diversion and abuse; 2) understanding of addiction terminology; 3) knowledge of federal and state laws governing opioid analgesic prescribing; 4) awareness of clinical practice guidelines for treating chronic pain; 5) concern about regulatory scrutiny; 6) beliefs about the legality and medical acceptability of prescribing opioids to treat chronic cancer and noncancer pain; and 7) characteristics of physicians, including information about their opioid prescribing practices. Identification of deficits in current knowledge, beliefs, attitudes, and prescribing practices, as well as their understanding of controlled substances laws and regulations would provide directions for future actions.

Methods

Six hundred Wisconsin physicians, randomly selected from the database of all licensed physicians provided by the Medical Examining Board of Wisconsin, were sent a 32-item questionnaire in July of 2005. No exclusions were made based on practice or specialty because all physicians in the state contribute to the overall prescribing environment. The questionnaire, a cover letter, and a $2 compensation were included in the initial mailing; the letter explained the project's purpose, assured respondent anonymity and confidentiality, and indicated that a summary of the results would be published. Ten days later, all nonrespondents were sent an additional mailing to encourage survey completion. Ten days after that reminder mailing, a researcher (M.Z.W.) telephoned a random one-third of those who had not yet responded to emphasize the importance of the research and to ask them to participate in the study. This study design and survey instrument were approved as exempt from review by the University of Wisconsin Institutional Review Board, and informed consent was obtained from all survey participants.

Frequency distribution information is provided for all reported results. A number of planned statistical comparisons were conducted using nonparametric methods for independent samples because all examined variables were categorical. The chi-square test of association compares groups on nominal and ordinal variables. All statistical tests were based on a Bonferroni correction family-wise significance level of 0.004 to control Type I error associated with multiple comparisons ([0.05 per comparison error rate] / [12 possible comparisons]). A significant chi-square result indicated substantial response variability between the physicians' characteristics and knowledge, belief, or attitude items. Adjusted standardized residuals identified where the statistical effect was located.

Results

Two hundred and sixteen surveys were returned from the 600 that were mailed, representing a 36% response rate. Table 1 contains demographic information about the respondents, their practice environment (including their prescribing practices), their training in pain management, and the perceived adequacy of their knowledge of treating pain. Eighty-seven percent of respondents were either in full- or part-time practice, while 51% had cared for a patient dying of cancer in the last 12 months. However, it also is important to recognize that, in this sample, 40% of all physicians were not currently treating patients with chronic cancer or noncancer pain.

Table 1

Frequency distributions related to demographic characteristics of survey respondents

Variable Frequency/Percent (N = 216) 
Sex 
  Female  
  Male  
  Unidentified  
Year of medical degree 
  Range 1946–2004 
  Mean 1987 
  Median 1991 
Status of medical practice 
  Full-time 161/75 
  Part-time 26/12 
  Retired 16/7 
  Not practicing 9/4 
Have DEA registration number 
  No 19/9 
  Yes 192/89 
  Missing 5/2 
Treat patients with chronic pain 
  No 87/40 
  Yes, either cancer or noncancer pain 56/26 
  Yes, both cancer and noncancer pain 67/31 
  Missing 6/3 
Cared for patient dying of cancer in last 12 months 
  No 101/47 
  Yes 109/51 
  Missing 6/3 
Number of outpatient Schedule IV opioid prescriptions per month 
  None 102/47 
  1–5 73/34 
  6–15 25/12 
  >15 10/5 
  Missing 6/3 
Number of outpatient Schedule III opioid prescriptions per month 
  None 61/28 
  1–5 57/26 
  6–15 47/22 
  >15 47/22 
  Missing 4/2 
Number of outpatient Schedule II opioid prescriptions per month 
  None 94/44 
  1–5 66/31 
  6–15 32/15 
  >15 20/9 
  Missing 4/2 
Personally investigated because of opioid prescription practices 
  No 212/98 
  Yes 2/1 
  Missing 2/1 
Know someone investigated because of opioid prescription practices 
  No 165/76 
  Yes 49/23 
  Missing 2/1 
Training in pain management 
  Medical school training only 16/7 
  Residency training only 22/10 
  Post-graduate training only 11/5 
  Combination of medical school, residency, and post-graduate training 110/51 
  No formal training 53/25 
  Missing 4/2 
Adequacy of pain management knowledge 
  Poor 38/18 
  Fair 83/38 
  Good 76/35 
  Excellent 17/8 
  Missing 2/1 
Variable Frequency/Percent (N = 216) 
Sex 
  Female  
  Male  
  Unidentified  
Year of medical degree 
  Range 1946–2004 
  Mean 1987 
  Median 1991 
Status of medical practice 
  Full-time 161/75 
  Part-time 26/12 
  Retired 16/7 
  Not practicing 9/4 
Have DEA registration number 
  No 19/9 
  Yes 192/89 
  Missing 5/2 
Treat patients with chronic pain 
  No 87/40 
  Yes, either cancer or noncancer pain 56/26 
  Yes, both cancer and noncancer pain 67/31 
  Missing 6/3 
Cared for patient dying of cancer in last 12 months 
  No 101/47 
  Yes 109/51 
  Missing 6/3 
Number of outpatient Schedule IV opioid prescriptions per month 
  None 102/47 
  1–5 73/34 
  6–15 25/12 
  >15 10/5 
  Missing 6/3 
Number of outpatient Schedule III opioid prescriptions per month 
  None 61/28 
  1–5 57/26 
  6–15 47/22 
  >15 47/22 
  Missing 4/2 
Number of outpatient Schedule II opioid prescriptions per month 
  None 94/44 
  1–5 66/31 
  6–15 32/15 
  >15 20/9 
  Missing 4/2 
Personally investigated because of opioid prescription practices 
  No 212/98 
  Yes 2/1 
  Missing 2/1 
Know someone investigated because of opioid prescription practices 
  No 165/76 
  Yes 49/23 
  Missing 2/1 
Training in pain management 
  Medical school training only 16/7 
  Residency training only 22/10 
  Post-graduate training only 11/5 
  Combination of medical school, residency, and post-graduate training 110/51 
  No formal training 53/25 
  Missing 4/2 
Adequacy of pain management knowledge 
  Poor 38/18 
  Fair 83/38 
  Good 76/35 
  Excellent 17/8 
  Missing 2/1 

Diversion and Abuse

When asked whether diversion and abuse of opioid pain medications was a problem in Wisconsin, 33% of physicians thought it was a moderate problem and 21% thought it was a serious problem. Only 2% of physicians surveyed said that diversion was not a problem in Wisconsin. In addition to concerns about the prevalence of opioid diversion or abuse, media coverage has the potential to affect physicians' views about the appropriateness of opioid prescribing for pain relief. Although most physicians surveyed (76%) said that the media coverage of opioid abuse had no impact on their opinion about the appropriateness of opioid prescribing for the general management of pain, 14% reported that such coverage had a negative impact on how they perceive such practice.

Addiction

Physicians were asked to define addiction to an opioid pain medication from a list of concepts provided. Twenty-three per cent of physicians believe addiction is defined purely by physiological characteristics, such as physical dependence/withdrawal symptoms and tolerance. Conversely, 19% correctly defined addiction as compulsive use despite harm. As would be expected, most physicians (56%) defined addiction as a combination of both physiological and behavioral characteristics.

Although respondents' definitions of addiction were not dependent on whether they currently treated patients for chronic pain associated with either cancer or noncancer conditions (χ2[4] = 8.85, P = 0.065[ns]), they were associated with the number of outpatient Schedule II opioid prescriptions written per month. Those writing the largest number of such prescriptions were significantly more likely to correctly define addiction solely in terms of behavioral characteristics (χ2[4] = 34.70, P < 0.0001).

Knowledge of Prescribing Laws

A notable proportion of respondents failed to answer survey items about current prescribing laws; for this reason, statistical analyses were not performed. However, respondents who provided an answer demonstrated a poor understanding of state and federal controlled substance laws (see Figure 1), with over 40% choosing “don't know” for almost every question. Only 29% knew that both federal and state laws permitted them to call in a Schedule II prescription in an emergency or to fax a Schedule II prescription to the pharmacy. Unfortunately, almost 40% of physicians incorrectly thought that both federal and state laws restricted physicians' prescriptions to only a 30-day supply of Schedule II medications, while about a third mistakenly believed that physicians can refill Schedule II prescriptions. Finally, only 38% of respondents currently understood that both federal and state laws permitted physicians to prescribe methadone to treat pain.

Figure 1

Physician responses to questions about whether federal or Wisconsin state laws mandate prescribing practices of opioids.

Figure 1

Physician responses to questions about whether federal or Wisconsin state laws mandate prescribing practices of opioids.

Knowledge of Clinical Practice Guidelines

Thirty-eight percent of respondents were aware of at least one clinical practice guideline for treating chronic pain. The most often-cited clinical practice guideline was from the Wisconsin State Medical Society, followed by guidelines created by other professional organizations specific to the physician's specialty, such as from the National Comprehensive Cancer Network (NACCN), the American College of Emergency Physicians (ACEP), the American Society of Anesthesiology (ASA), the American College of Physicians (ACP), the American Academy of Neurology (AAN), the Agency for Health Care Policy and Research (AHCPR), and the World Health Organization (WHO).

Perhaps not surprisingly, physicians who did not prescribe Schedule II opioids were less likely to be aware of clinical practice guidelines relating to chronic pain management (χ2[2] = 12.63, P < 0.002). Also, physicians who were unaware of clinical practice guidelines tended not to treat patients for chronic cancer or noncancer pain (χ2[2] = 18.01, P < 0.0001).

Investigation by Regulatory Agencies

Most respondents (59%) reported no concern that their opioid prescribing practices might be investigated; however, 24% reported being somewhat concerned, 10% were moderately concerned, and 3% had extreme concern. Only two respondents reported having been investigated for prescribing opioids, but 23% know someone who had been investigated although the outcomes of the investigations were unknown. Interestingly, even though most physicians were not concerned about being investigated, many reported that they used the following strategies at least occasionally to avoid investigation by a regulatory agency:

  • 46% limited the number of refills,

  • 35% prescribed an opioid in a lower schedule,

  • 35% prescribed a smaller quantity, and

  • 19% prescribed a lower dose.

Physicians' concerns about having their opioid prescribing investigated were associated with the frequency with which they changed their prescribing practices. Table 2 contains the chi-square values for each prescribing practice. Those who reported no concern about having their opioid prescribing investigated were less likely to report prescribing opioids in lower doses, smaller quantities, and lower schedules, and never limited refills of opioids.

Table 2

Chi-square analyses of reported frequency of changing prescribing practices by level of concern about regulatory investigation

Prescribe Lower Dose N = 195
 
Not Concerned As Least Some Concern 
Never 54% 26% 
At least occasionally*  8% 13% 

 
 χ2(1) = 12.29, P < 0.0001 

 
Prescribe Smaller Quantities N = 195
 
Not Concerned At Least Some Concern 

 
Never 46% 16% 
Occasionally 12% 11% 
Often or Always  4% 12% 
 χ2(2) = 26.40, P < 0.0001 

 
Limit Number of Refills N = 195
 
Not Concerned At Least Some Concern 

 
Never 38% 11% 
Occasionally  5%  8% 
Often or Always 19% 19% 
 χ2(2) = 20.26, P < 0.0001 

 
Prescribe Lower Schedule N = 192
 
Not Concerned At Least Some Concern 

 
Never 45% 16% 
Occasionally 11% 14% 
Often or Always  6%  8% 
 χ2(2) = 17.95, P < 0.0001 
Prescribe Lower Dose N = 195
 
Not Concerned As Least Some Concern 
Never 54% 26% 
At least occasionally*  8% 13% 

 
 χ2(1) = 12.29, P < 0.0001 

 
Prescribe Smaller Quantities N = 195
 
Not Concerned At Least Some Concern 

 
Never 46% 16% 
Occasionally 12% 11% 
Often or Always  4% 12% 
 χ2(2) = 26.40, P < 0.0001 

 
Limit Number of Refills N = 195
 
Not Concerned At Least Some Concern 

 
Never 38% 11% 
Occasionally  5%  8% 
Often or Always 19% 19% 
 χ2(2) = 20.26, P < 0.0001 

 
Prescribe Lower Schedule N = 192
 
Not Concerned At Least Some Concern 

 
Never 45% 16% 
Occasionally 11% 14% 
Often or Always  6%  8% 
 χ2(2) = 17.95, P < 0.0001 
*

The variable categorization is unique because there were too few cases in the “Often or Always” category to analyze separately.

Physicians also were asked to rank the agencies that they considered most likely to investigate improper prescribing of controlled substances. Forty percent selected the DEA as the foremost agency, while 28% considered the Medical Examining Board to be the agency most likely to investigate. Other agencies, such as the Controlled Substances Board, the local police/sheriffs department, and the Pharmacy Examining Board, as well as the Office of the Attorney General, were about equally ranked (i.e., ranked second or third). In addition, 27% of respondents mistakenly thought that the DEA had the authority to revoke a physician's license to practice medicine, while 48% believed that the DEA had no such authority and 23% were unsure.

Attitudes toward Prolonged Prescribing for Chronic Pain

Physicians also were surveyed about the legality and medical acceptability of prescribing opioids for more than several months in four different patient scenarios involving chronic pain: 1) chronic cancer pain, 2) chronic cancer pain with a history of opioid abuse, 3) chronic noncancer pain, and 4) chronic noncancer pain with a history of opioid abuse. The available response options were that the practice was: 1) lawful and generally accepted medical practice, 2) lawful but generally not accepted medical practice and should be discouraged, 3) probably a violation of federal or state controlled substances or medical practice laws and should be investigated, and 4) don't know. Table 3 contains the specific response frequencies and percentages for each chronic pain scenario.

Table 3

Attitudes toward prolonged opioid use for separate pain scenarios (frequency/per cent)

 Probably a Violation of Law and Should be Investigated Lawful, but Generally not Accepted Medical Practice; Should be Discouraged Lawful and Generally Accepted Medical Practice Don't Know Missing Data 
A patient with chronic cancer pain  4/2  12/6 186/86  8/4  5/2 
A patient with chronic noncancer pain  8/4  76/35 110/51 14/7  8/4 
A patient with chronic cancer pain and a history of substance abuse 12/6  47/22 130/60 19/9  8/4 
A patient with chronic cancer pain and a history of substance abuse 45/21 120/56  24/11 17/8 10/5 
 Probably a Violation of Law and Should be Investigated Lawful, but Generally not Accepted Medical Practice; Should be Discouraged Lawful and Generally Accepted Medical Practice Don't Know Missing Data 
A patient with chronic cancer pain  4/2  12/6 186/86  8/4  5/2 
A patient with chronic noncancer pain  8/4  76/35 110/51 14/7  8/4 
A patient with chronic cancer pain and a history of substance abuse 12/6  47/22 130/60 19/9  8/4 
A patient with chronic cancer pain and a history of substance abuse 45/21 120/56  24/11 17/8 10/5 

Results demonstrated that physicians were most confident about the legality and medical acceptability of prescribing opioids for more than several months to treat a patient with pain from cancer, but confidence in the legal and medical appropriateness of this practice decreased notably when the cancer patient with chronic pain also had a history of substance abuse. If the patient's chronic pain was of noncancer origin, slightly less than two-thirds of respondents were confident that this practice was legal or medically accepted. Finally, only about 1 out of 10 respondents considered opioid prescribing for more than several months to a patient with chronic noncancer pain and a history of substance abuse as legal and accepted medical practice.

As shown in Table 3, viewing the prescribing practices as a violation of law was generally infrequent, representing at most 6% of the sample (except when the patient had both noncancer pain and a history of substance abuse [21%]). For statistical analysis of these items, we decided to combine categories into a single one representing either a violation of law or unacceptable medical practice. There still were too few responses to the chronic cancer pain scenario to conduct comparisons. In addition, for any of the four pain scenarios the number of “don't know” responses did not exceed 9%, which did not yield a sufficient number of responses to analyze as a separate category. As a result, all “don't know” responses were excluded from the analyses.

When evaluating whether physicians treating patients with chronic pain held different attitudes toward the appropriateness of prescribing for these pain scenarios, compared with those who did not treat such patients, no significant relationship emerged that conformed to this study's family-wise P value of 0.004, although two of the three comparisons approached significance in relation to a more traditional P value of 0.05. A clear association was found between physicians' prescribing practices and the extent to which they viewed the prescribing for chronic noncancer pain as appropriate. Those physicians who did not write prescriptions for Schedule II opioids were more likely to consider opioid treatment for patients with chronic noncancer pain as unlawful or unacceptable medical practice (χ2[2] = 13.83, P < 0.001). Furthermore, there was no statistically significant relationship between the number of outpatient prescriptions written for a Schedule II opioid and practitioners' attitudes about prolonged prescribing when the patient had a history of substance abuse, in both the cancer and noncancer pain scenarios (χ2[2] = 8.57, P = 0.014 and χ2[2] = 8.80, P = 0.012, respectively).

Discussion

Wisconsin physicians reported frequently-erroneous knowledge, beliefs, and attitudes about the use of opioid analgesics to relieve chronic pain, such as those relating to the appropriateness of prescribing for chronic pain, the characteristics of addiction, federal and state regulatory prescribing requirements, and the authority of the DEA. Respondents' reported practice patterns, coupled with their knowledge, beliefs, and attitudes, can result in inadequate prescribing and undertreatment of pain among patients with chronic pain. This is especially disturbing because half of the physicians had cared for patients dying of cancer in the past 12 months and 40% (unreported frequency) were caring for patients with pain related to cancer or its treatment, where opioids are considered critical for effective pain management.

Physicians generally are uneasy about using opioid analgesics to treat patients with chronic pain, especially if opioids are to be used for long periods [16,32,33]. It was discouraging that some respondents considered it either illegal or medically unacceptable to prescribe opioids to treat patients with chronic pain. An even greater number of respondents thought it was unlawful or unacceptable to prescribe opioids for chronic noncancer pain, especially when the patient had a history of substance abuse, despite numerous studies that support such a practice with the proper follow-up and monitoring [34,35]. Furthermore, there are several recent studies demonstrating that a history of substance abuse does not necessarily predict future abuse of prescription opioids when used for the legitimate medical purpose of pain relief [17,32,36]. The respondents' attitudes about the legality of opioid prescribing indicate that patients with a history of substance abuse are at a high risk for undertreatment, even when they are suffering from severe chronic pain. Physicians' uneasiness about prolonged opioid prescribing, especially for Schedule II opioids, was shown here to reflect their inexperience with the clinical use of these medications. This interpretation coincides with the finding that 40% of the surveyed physicians reported that they did not treat patients with either chronic cancer or noncancer pain in the last 12 months. However, the attitudes of physicians about the appropriate use of opioids, even those physicians who usually do not prescribe them, can influence the practice environment in the state, especially if they are in a position to train other physicians.

Survey respondents also mirrored the national confusion about the meaning of addiction. Addiction, tolerance, and physical dependence currently are considered distinct phenomena with separate neurophysiological mechanisms [18]. However, healthcare professionals often view these conditions as synonymous, including most responding Wisconsin physicians. Misunderstandings about the concept of addiction have the potential for patients, who are using opioids for a prolonged period of time, to be labeled as “addicts” solely because they have developed physical dependence and would experience withdrawal symptoms upon abruptly ceasing their medication use. Such a diagnosis is inappropriate because the patient is not displaying signs of craving or compulsive use despite harm, which are the essential characteristics of addiction [37]. Patients and members of the general public also hold similar misbeliefs and conclude that any use of opioids, even if for a legitimate medical purpose, will lead to addiction [38]. These unfounded fears often contribute to avoidance of these medications even when they are medically warranted. Continued education of both the healthcare community and the public is necessary to avoid inappropriate labeling that can interference with adequate patient care.

General concerns about the deleterious public health consequences posed by opioids can be further intensified by sensationalized national and state news reports involving diversion and abuse of opioid medications. It is surprising, therefore, that most physicians reported that media coverage about opioid abuse and diversion had no impact on their views about the appropriateness of opioid use for pain management. While this is encouraging in one respect, a notable percentage of physicians consider diversion and abuse of prescription opioids a significant problem in Wisconsin, despite the absence of evidence to support this belief. Notwithstanding a relatively consistent national focus on opioid abuse and diversion issues since around 2000, there is a continued need for well-controlled empirical studies to measure their actual prevalence at the state and national levels and to quantify the various sources of diverted drugs [26,39].

Most Wisconsin physicians surveyed also noted that they were not concerned about being investigated for their prescribing practices, although about 40% expressed at least some concern and 23% knew someone who had been investigated. A large proportion of respondents still changed aspects of their prescribing to decrease the likelihood of being investigated. Although it is encouraging that lowering the dose of an opioid was the least frequent practice, almost one out of five respondents reported doing this at least occasionally. The most common changes involved limiting refills and prescribing lower-schedule medications. As refills are lawful only for lower-schedule medications (e.g., Schedules III, IV, and V), which are not indicated for severe pain, these practices like the others have the potential to interfere with the treatment of pain, especially if the patient has severe chronic pain. Physicians who reported no concerns about regulatory investigation tended to avoid these practices, which emphasizes the need to effectively address these concerns not only for the physicians' well-being but also to minimize any potential practice patterns that could negatively impact patients.

Results clearly demonstrated that many physicians, including those who prescribe opioids, had a poor knowledge of prescribing requirements contained in federal and state controlled substances regulations; in fact, “don't know” was the most frequent response for all but one of these five items. Almost half of the respondents did not know whether they could call in a prescription for a Schedule II opioid in an emergency, while 44% were unsure whether they could prescribe methadone for pain control. Physicians displayed the most confidence about whether federal and state laws limited the amount of a Schedule II opioid that can be prescribed at one time to a 30-day supply, with nearly 40% believing that both federal and state law required such a limit. Ironically, neither federal nor state law requires a 30-day supply limit. This lack of knowledge about the laws and regulations governing the prescribing of Schedule II opioid analgesics are allowed under federal and state law has the potential to needlessly restrict appropriate assess to these medications for patients who require them medically. Interestingly, similar misperceptions were ascertained from a previous survey of Wisconsin physicians conducted in 1991 [27].

When physicians were asked to identify the clinical practice guidelines that informed their treatment of chronic noncancer pain, many responses were given and typically represented guidelines from organizations specific to their specialty such as NACCN, ACEP, AAN, and ASA. In addition, the purpose of these clinical practice guidelines was to address pain management issues relevant to the specialty's practice environment (e.g., pain management in the emergency department, cancer pain management, etc.). Only the ASA produced clinical practice guidelines for both cancer pain and chronic pain management. Some cited the WHO as having a clinical guideline, but the three-step analgesic ladder establishes a set of cancer pain management principles and does not constitute a clinical practice guideline [4]. The AHCPR also was cited as a source for clinical practice guidelines for cancer pain management but these guidelines, published in 1994 and now obsolete, have been replaced by cancer pain management guidelines from the American Pain Society. Statistical analyses confirmed that physicians who did not treat patients with chronic pain or who did not prescribe Schedule II opioids were less aware of specific clinical practice guidelines.

A notable proportion of the sample (40%) believed that investigations of “improper” prescribing were the purview of law enforcement (i.e., the DEA), rather than their professional regulatory agency (i.e., the Wisconsin Medical Examining Board). In addition, over one-quarter of respondents thought the DEA could revoke their license, instead of recognizing this as a responsibility solely of the state medical board. The DEA's drug control authority relates to efforts to reduce unlawful prescribing. By law, a prescription is only lawful when issued “… for a legitimate medical purpose by an individual practitioner acting in the usual course of his professional practice”[40]. Examples of unlawful prescribing include exchanging prescriptions or medications for money or sex, and when a physician knows that the prescription medications are being abused or diverted. Legislative history makes it clear that the federal government is obligated to create criteria for drug control, such as the legal parameters of prescribing controlled substances (stated above), while state healthcare licensing boards regulate professional practice including prescribing [41]. This is a critical distinction that needs to be recognized—the state medical board should be the agency considered primary when investigating improper prescribing.

Despite these striking results, several important limitations characterize this study and should be mentioned. First, there is no way to directly confirm at this time whether the knowledge, beliefs, attitudes, and opioid prescribing practices of Wisconsin physicians demonstrated by this survey represent a unique profile or are generalizable to physicians practicing in other states. Similar surveys are currently being conducted in Washington and Georgia, however, and will eventually create the opportunity to compare responses among the samples obtained from these states in an effort to determine response similarities and evaluate the level of generalizability. Second, given the 36% response rate, a question remains about the sample representativeness to the entire state population of physicians. It is possible that those physicians with strong views about pain management issues were more likely to respond to this survey, but this explanation is weakened by the fact that 40% of the sample reported that they did not treat either chronic cancer or noncancer pain. Without confirmatory information, it remains probable that the views expressed by this sample may not be representative of all Wisconsin physicians. Third, the survey instrument was not psychometrically evaluated to determine its reliability or content validity, but most items were based on previously-published surveys that examined similar issues [13,14,27,42]. Fourth, most survey research is vulnerable to the prospect of respondents providing socially desirable answers, and we attempted to minimize the likelihood for social desirability by guaranteeing respondent anonymity and maintaining response confidentiality. Finally, although a survey of practicing Wisconsin physicians was conducted in 1991 [27], which addressed a few of the issues that were evaluated in this most recent questionnaire, substantially inconsistent wording of questions and response formats between the two surveys did not allow for direct statistical comparisons. In this way, it was not possible to assess changes in practitioner knowledge, attitudes, and beliefs that have occurred over this 15-year period.

Conclusion

The past 15 years in Wisconsin have involved vigorous efforts to inform physicians about the role of opioid pain medications and their appropriate use in everyday practice [43], including a practice guideline issued by the State Medical Society [44] and a more recent regulatory policy from the Medical Examining Board [45]. Still, many physicians continue to report inadequate knowledge of, as well as little formal training in, the prescribing of opioids to treat chronic pain and to a large extent mirror results from a state survey conducted in the early 1990s. Slightly more than half of respondents treated patients with chronic pain of either cancer or noncancer origin. A similar number prescribed Schedule II opioids that are indicated for the relief of severe pain. Moreover, half of all physicians had cared for at least one patient dying of cancer in the past 12 months, which is a practice that would likely require the use of opioids as these medications are a critical component of pain management for this patient population.

It is concerning that so few responding physicians have the knowledge and training to effectively treat patients experiencing chronic pain. Findings from this survey continue to question the practical utility of issuing clinical or regulatory guidelines in an attempt to influence physician awareness, medical practice, and patient care. It is apparent that further efforts are necessary to inform Wisconsin physicians' knowledge, beliefs, attitudes, and, ultimately, their prescribing practices related to treating chronic cancer and noncancer pain. Only then will chronic pain be adequately controlled and patient quality of life improved.

Acknowledgement

Funding was provided by the Shapiro Summer Research Program at the University of Wisconsin School of Medicine and Public Health and the University of Wisconsin Paul P. Carbone Comprehensive Cancer Center.

These data were presented in part at the 25th Annual Scientific Meeting of the American Pain Society, in May 2006.

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A grant was provided by the Shapiro Summer Research Program at the University of Wisconsin School of Medicine and Public Health and the University of Wisconsin Paul P. Carbone Comprehensive Cancer Center.