Physician Attitudes and Stigma May Hinder Patient Care with Opioid Prescribing, Pain Management, and Addiction Treatment Open Access

John, Samuel (Spring 2020)

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Importance: Physician stigma has been found to exist with substance abuse, however, less research shows how such attitudes have specifically shaped physician opioid prescribing. Given the magnitude of the opioid epidemic, analyzing how physician stigma and attitudes influence prescribing can elucidate how physicians treat pain, and offer suggestions for appropriate pain control.

Objective: To determine if:

1)    Physicians with stigma towards patients with opioid addiction (opioid use disorder or OUD) are more likely to give substandard patient care towards opioid using patients and patients in chronic pain.

2)    Physicians who dislike prescribing opioids in chronic dosages are more likely to give substandard patient care towards opioid using patients and patients in chronic pain.

Design/Setting, Participants: Online survey study, observational; 68 Emory University physicians from all specialties of all ages, with a DEA number to certify legal opioid prescriptions.

Main Outcome and Measure: SurveyMonkey online survey devised from physician expertise on opioid prescribing and pain management, to gauge predictors of physician stigma and assess their patients’ patient care using commonly accepted standards of care and the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain. Statistical analysis used Principal Component Analysis (PCA), followed by General Linear Modeling.

Results: PCA, linear regression and ANOVA found that physicians who are uncertain with opioids tend to have stigmatizing attitudes towards opioids and addiction, and also tend to dislike opioids. Uncertain physicians gave significantly worse patient care (p= 0.0054). Within other specialists, less knowledgeable and experienced physicians gave significantly worse care (p= 0.0054). Pain specialists were least uncertain (p= 0.015), while ER and other specialists were the most uncertain with opioids on average and were the least knowledgeable (p= 0.034). ER and Other specialists also delivered significantly worse care than pain specialists (p<0.0001). Specialty was a stronger predictor of patient care than uncertainty or knowledge/experience, according to AIC scores. Females were significantly less uncertain about opioids (p= 0.017).

Conclusion and Relevance: Results suggest that stigma can manifest as uncertainty, which can significantly worsen pain care. Given specialty-specific worsened care, this suggests that tailoring opioid trainings to non-pain specialists may be necessary. 

Table of Contents

Table of Contents

1.     Introduction...1

2. Methods and Hypotheses...6

2.1 Survey Design...6

2.2 Principal Component Analysis and Other Statistical Methods...9

3. Results...13

3.1 Unprocessed Survey Results and Transformation...13

3.2 PCA Results: PC1 and PC2 Interpretations...15

3.3 Demographic Influences on Uncertainty with Opioids (PC1) and Knowledge/Experience (PC2)...20

3.4 Patient Care vs Uncertainty with Opioids (PC1) and Knowledge/Experience (PC2)...23

3.5 Subset Analysis within Specialties: Patient Care vs Uncertainty and Knowledge/Experience...25

4.  Discussion...29

4.1 Importance...29

4.1.1 Hypothesis Testing: Stigma’s Influence on Patient care...29

4.1.2 Reviewing our Interpretations: Evidence in Literature and Significance of PCs...29

4.1.3 Specialty, Uncertainty, and Worse Patient care: Training as a Solution?...31

4.1.4 Sex Comparison to Uncertainty with Opioids (PC1)...32

4.1.5 Miscellaneous: Patient Care Significance and Honesty vs Compliance...33

4.2 Limitations and Future Directions...33

5.  Conclusions...34

6. Appendix: Tables and Figures...37

Table A1: Survey Questions Categories and Abbreviations...37

Figure A1: Raw Response Frequencies (n= 70), Prior to Eliminating 2 Incomplete Responses...40

Fig. A2.1: Transformations...54

Fig. A3 Sample SAS Code...56

Works Cited...57

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