LEBANON – A new study by Dartmouth Hitchcock and the University of Michigan, released in the Annals of Family Medicine, says not only that patients using opioids are generally less healthy than patients who are not, but indicates that a lot of physician prescribing practices may be linked to patient satisfaction surveys, part of the way physicians get paid.
A third premise indicates that there are similarities between the overprescribing practices of opioids and that of antibiotics. World health leaders are already concerned about superbugs, diseases linked to antibiotic resistance, which are made worse by the overprescribing of antibiotics.
Anesthesiologist Dr. Brian Sites is a lead author on the study. He said part of the way physicians get paid is based on patient satisfaction surveys, but that patients with common musculoskeletal conditions who use opioids may be more satisfied but have poorer health when compared to patients who do not use opioids.
The research team’s primary interest was to determine if a patient’s perception of their care was associated with the number of opioid prescriptions they received from their health care providers.
“Patient satisfaction is an important driver of health care reimbursement mechanisms,” said Sites of the study, which was published in the January/February 2018 Annals of Family Medicine. “We found, using population-based data, that patients suffering from chronic musculoskeletal disorders (such as arthritis) rate their satisfaction with care higher when they receive more opioid prescriptions. This higher satisfaction exists even though these patients have poorer physical and mental health compared to their counterparts who do not take opioids.”
As clinician compensation is increasingly linked to patient satisfaction, and as the United States struggles with an epidemic in opioid use, the authors suggest it is imperative to determine whether improved satisfaction with care is associated with demonstrable health benefits.
The researchers sampled data from nearly 20,000 adults who self-reported musculoskeletal pain from arthritis or other limitations on physical functions because of pain. All the patients were anonymous to the researchers and are part of a national database used for clinical studies. Nearly 13 percent of the patients were prescription opioid users and 41 percent were heavy users.
“The extent to which prescription opioid use is associated with patient satisfaction is currently unknown,” the researchers report. “The rise in the prescription of opioids was, presumably, initially driven by a desire to improve the well-being of patients having pain. If, in fact, prescription opioid use is associated with higher patient satisfaction, such payment incentives may be perpetuating the prescribing of these medications.”
The researchers noted that opioid users were slightly older than non-users, but there were large differences in how they reported their health status. “Compared with non-users, users tended to have poorer physical and mental health. For instance, more than one-half of the opioid users rated their physical health as fair to poor, compared with one-fifth of non-users. Additionally, 75 percent of opioid users rated their pain as moderate to extreme, compared with only 31 percent of non-users.”
A troubling observation reported in the research is that health care reimbursement models “may favor overprescribing to optimize patient satisfaction through such mechanisms as the Hospital Consumer Assessment of Healthcare Providers and Systems.”
“Our findings do not allow us to determine if overprescribing or unnecessary prescribing of opioids is actually occurring, but they do highlight the future need to establish whether the greater patient satisfaction is actually associated with better health or less disability,” said Sites.
Sites said that if there is that link, the result is that it is just perpetuating the crisis because it is known now that prescribed opioids are often a gateway to more serious drugs like heroin and fentanyl, drugs people may turn to when they can no longer acquire prescription narcotics.
Sites said the survey showed that patient satisfaction is not linked to pain in most cases, and that those using the narcotics seemed sicker, both physically and mentally than those not taking opioids. He said this indicates the medication may not be as effective as it is thought to be.
“The CDC reported that despite a quadrupling of opioid prescriptions, the reports of pain seem to be the same,” said Sites.
In trying to explain why overprescribing by physicians may be a pattern, the study noted:
“We hypothesize that perhaps the improved satisfaction from opioids may partially be explained by an analogous situation that has been previously documented with antibiotics prescribed for likely viral upper respiratory infections. Several studies indicate that the clinician’s desire to accommodate patient and parent expectations leads to overtreatment and overprescribing of oral antibiotics. Another possible explanation for our findings is that chronic opioid therapy may improve untreated mood disorders, which are highly prevalent, and the patient may perceive alleviation of these symptoms and report this benefit in the form of greater health care satisfaction.”
“As physicians, and as patients, we need to overcome the culture where we think there is a pill for every woe,” said Sites. “The premise is similar. When patients go to the doctor, particularly with smaller children, they want something done. Antibiotics are routinely given for viral infections and are not useful there. The premise of doing this with opioids is much more serious.”
What is needed, said Sites, is a more comprehensive look at alternatives to opioids. He said there is thought now that a combination of acetaminophen and ibuprofen can be just as effective. And alternative therapies like acupuncture should be explored.
“That is by no means intended to say there are no situations where opioids are appropriate because they certainly are sometimes,” said Sites. “We need to look at whether the drugs are helping with meaningful improvements. Can the patients sleep? Can they get back to work? We need to factor this in because once a person is using opioids for chronic conditions, it is incredibly hard to get them off it.”
The researchers call for future studies to more rigorously evaluate the complex relationships among opioid use, patient satisfaction, physical behaviors and health metrics.
“We are a consumer-driven society,” said Sites. “Patients want satisfaction, but a conflict exists between want and need. We need to find a way to balance that and to do the right thing. I don’t know the answer. This is a uniquely American problem, where we prescribe enough medication that we could supply a bottle for every American family.”