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Factors that Influence Physician Identification of Potential Opioid Misusers

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Background: Chronic pain and subsequent prescription opioid misuse are common issues. When prescribing opioid analgesics, emergency medicine providers may subconsciously screen patients by specific patient behaviors. No previous reports have identified if this occurs or what the characteristics are. Objective: To examine factors that emergency medicine providers use to identify potential prescription opioid misusers. Methods: We conducted an anonymous survey of emergency medicine providers in a military tertiary care hospital, We created a l3-qucstion survey with fixed response and multiple-answer questions on emergency medicine provider1s perceptions of "hard" (physicallobjective) and 11 SOft11 (behavioral) signs of opioid misusers. The survey was revised after a pilot sample. Conclusions: EM providers use specific signs and behaviors to detect opioid misuse and to support their opioid prescriplion decision. Irrespective of experience, almost 50% take into account information in the medical record.

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“Hard” versus “soft” patient cues that influence emergency medicine provider perception of potential opioid misusers Lisa M. Manina, Shawn M. Varney, Vikhyat S. Bebarta, Katherine R. Carey, Victoria J. Ganem, Rosemarie G. Ramos Background: Chronic pain and its resultant prescription opioid misuse are common in the United States. By identifying patient characteristics that influence their decision to prescribe opioid analgesics, emergency medicine providers (EMPs) may treat pain more appropriately. Objective: We sought to examine factors that EMPs perceive may identify potential opioid misusers. Methods: We conducted an anonymous survey of EMPs (physicians, physician assistants [PA], nurse practitioners) in a military tertiary care hospital. We created a 13-question survey with fixed response (closed end) and multiple-answer questions on prescriber perceptions of “hard” (physical/objective) and “soft” (behavioral) signs of opioid misusers. The survey was revised after a pilot sample. We expected a 9.8% margin of error and 98% response rate based on a sample size of 100 subjects. Patterns of responses were assessed using rank-ordered and binary logistic regression. Results: 90 surveys were completed (100% response rate). Of respondents, 53.3% were age 25-35 years, 31.1% were 36-45 years, 79% were male, 77% were physicians, 16% PAs, and 56% had practiced 5 years or less. Irrespective of gender or length of practice, the most frequent choice for “hard cues” suggesting risk of opioid misuse was IV drug abuse. Among “soft cue” choices, the most frequent response was “patient provides unbelievable stories or exaggerated explanations regarding why they need more pain pills,” which was also consistent when examined by gender or length of practice. The 2nd and 3rd most frequent responses involved the willingness to review medical records, which may reflect the increasing use of electronic medical records. When asked to select from a list which chief complaints they felt were most frequently associated with possible opioid misuse, EMPs cited back pain most frequently, while extremity pain was the least likely to generate suspicion. A possible explanation may be that extremity injury can often be corroborated by a radiographic documentation in the patient’s medical history. Conclusions: We found a concurrence among EM providers regarding specific signs and behaviors that suggest opioid misuse and support their opioid prescription decisions. Also, irrespective of experience, almost 50% were willing to pursue information in the medical record for opioid prescription decision-making.

“Hard” versus “Soft” Patient Cues That Influence Emergency

Medicine Provider Perception of Potential Opioid Misusers

Mannina LM, Varney SM, Bebarta VS, Carey KR, Ganem VJ, Ramos RG

Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX

Results

• 90 surveys completed (100% response rate)

• 53.3% were ages 25-35, 31% ages 36-45

• 79% male, 77% physicians, 16% PAs, 6% NPs

• 56% had practiced 5 years or less

• Figure 1 shows most common chief complaints suggesting

opioid misuse

Methods

• Anonymous survey of EMPs (physicians, physician

assistants [PA]) in a military tertiary care hospital

• 13-question survey with fixed response and multiple-answer

questions on EMP perceptions of “hard” (physical/objective)

and “soft” (behavioral) signs of opioid misusers

• Survey was revised after a pilot sample

• For a sample size of 90 subjects we expected a 9.8% margin

of error and 98% response rate

• Descriptive statistics

Background

• Chronic pain and subsequent prescription opioid misuse are

common

• When prescribing opioid analgesics, emergency medicine

providers (EMPs) may subconsciously screen patients by

specific patient behaviors

• No previous reports have identified if this occurs or what the characteristics are

Conclusions

• EM providers use specific signs and behaviors to detect

opioid misuse and to support opioid prescription decisions

• Provider gender did not impact choice of hard or soft signs

• Provider experience level did not affect 1st choice of hard

signs but did influence selection of soft signs

• Almost 50% of providers use medical record information

Limitations

• Anonymous without follow-up

• Some answers may not be truthful

• Single site

• Military providers (so may not be applicable to civilians)

Results (Cont’d)

• Most providers reported that exaggerated pain scores were

a warning sign for opioid misuse (Figure 2)

• Table 1 shows most common hard signs EMPs used to

identify potential prescription opioid misuse

Top two 1st choices were similar irrespective of gender or

years in practice

• Second most common hard sign is shown in Table 1

• Soft signs are shown in Table 2

• Responses for 1st choice of soft signs were similar by

provider gender but not practice years

• EMPs practicing 5 years or less reported

Exaggerated explanations (24%) and patient appearance

of comfort (24%) were most common soft signs

• EMPs practicing more than 5 years reported

Exaggerated explanations (32%) and excessive ED visits

for pain (28%) most commonly suggested misuse

Background

Methods

Results

Limitations

Results Conclusions

Results

Disclaimer: The views expressed herein are solely those of the authors and do not represent the official

views or policies of the U.S. Government, Department of Defense, or U.S. Air Force

Emergency medicine providers

( n = 90)

1st

Choice

2nd

Choice

IV drug abuse (track marks) 42 22

Medical record review reveals

excessive opioid prescriptions

41 29

Allergy to other pain medications 6 11

History of hospitalization for

overdose/depression/rehabilitation

3 19

Patient affect 1 1

Odor of tobacco/alcohol 3

Poor hygiene including oral

hygiene/missing teeth

2

Criminal background 1

Poorly educated (less than high school) 1

Tattoos 1

Emergency medicine providers

( n = 90)

1st

Choice

2nd

Choice

Patient provides unbelievable stories or

exaggerated explanations

28 10

Excessive ED visits for pain 22 10

Patient looks comfortable from a distance

but in severe pain when you enter the

room

19 21

Patient refers to drugs by name 17 24

When you present your plan for

analgesia (NSAIDs), Pt states, “That

never works!”

6 11

History is inconsistent with presentation 4 11

Excuses for missing clinic appointments 1 2

Patient reports not enough money to fill

prescription, so needs more meds now

1 2

Patient denies having a PCM, or does

not know who it is

1

Objective

• To examine factors that EMPs use to identify potential

prescription opioid misusers

Objective 0

20

40

60

80

100

All Females Males Practicing < 5 years Practicing > 5 years

Pro

po

rtio

n t

hat

sele

cte

d t

his

ch

ief

co

mp

lain

t

Figure 1. The most and least frequently selected chief complaint that causes concern for opioid abuse

Back pain Extremity pain

Figure 2: Chief complaints providers associated

with opioid misuse

Table 1: Ranking of patient characteristics providers

used as Hard Signs suggesting opioid misuse

Table 2: Ranking of patient characteristics providers

used as Soft Signs for opioid misuse

0

10

20

30

40

50

60

70

80

90

100

Abdominalpain

Back pain Extremitypain

Dental pain Headache

Varney SM, Bebarta VS, Mannina LM, Ganem VJ, Carey KR, Ramos RG

Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX

“Hard” versus “Soft” Patient Cues That Influence Emergency Medicine Provider Perception of Potential

Opioid Misusers

Disclaimer

The views expressed herein are solely those of the authors and do not represent the official views or policies of the

U.S. Government, Department of Defense, or U.S. Air Force

Background • Chronic pain and subsequent prescription opioid misuse are

common • When prescribing opioid analgesics, emergency medicine

providers (EMPs) may subconsciously screen patients by specific patient behaviors

• No previous reports have identified if this occurs or what the characteristics are

Methods • Anonymous survey of EMPs (physicians, physician assistants

[PA]) in a military tertiary care hospital • 13-question survey with fixed response and multiple-

answer questions on EMP perceptions of “hard” (physical) and “soft” (behavioral) signs of opioid misusers

• Survey was revised after a pilot sample • Goal: sample size of 90 subjects, a 9.8% margin of error,

and a 98% response rate • Descriptive statistics analysis

Results • 90 surveys completed (100% response rate) • 53.3% were ages 25-35, 31% ages 36-45 • 79% male, 77% physicians, 16% PAs, 6% NPs • 56% had practiced 5 years or less

Results • Most providers reported that exaggerated pain scores were

a warning sign for opioid misuse • Top two #1 choices for hard signs EMPs used to identify

potential prescription opioid misuse were similar irrespective of gender or years in practice

• Responses for 1st choice of soft signs were similar by provider gender but not practice years

Results • EMPs practicing 5 years or less reported

Exaggerated explanations (24%) and patient appearance of comfort (24%) were most common soft signs

• EMPs practicing more than 5 years reported Exaggerated explanations (32%) and excessive ED visits

for pain (28%) most commonly suggested misuse

Limitations • Anonymous without follow-up • Some answers may not be truthful • Single site • Military providers (may not be applicable to civilians)

Conclusion • EM providers use specific signs and behaviors to detect

opioid misuse and to support opioid prescription decisions • Provider gender did not impact choice of hard or soft signs • Provider experience level did not affect 1st choice of hard

signs but did influence selection of soft signs • Almost 50% of providers use medical record information