Fischer Michael A, McKinlay John B, Katz Jeffrey N, Gerstenberger Eric, Trachtenberg Felicia, Marceau Lisa D, Welch Lisa C
Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America.
New England Research Institutes (NERI) and Division of Medicine, Watertown, Massachusetts, United States of America.
PLoS One. 2017 Jun 23;12(6):e0178690. doi: 10.1371/journal.pone.0178690. eCollection 2017.
Pain complaints are common, but clinicians are increasingly concerned about overuse of opioid pain medications. This may lead patients with actual pain to be stigmatized as "drug-seeking," or attempting to obtain medications they do not require medically. We assessed whether patient requests for specific opioid pain medication would lead physicians to classify them as drug-seeking and change management decisions.
Mixed-methods analysis of interviews with 192 office-based primary care physicians after viewing video vignettes depicting patients presenting with back pain. For each presentation physicians were randomly assigned to see either an active request for a specific medication or a more general request for help with pain. The main outcome was assignment by the physician of "drug-seeking" as a potential diagnosis among patients presenting with back pain. Additional outcomes included other actions the physician would take and whether the physician would prescribe the medication requested. A potential diagnosis of drug-seeking behavior was included by 21% of physicians seeing a specific request for oxycodone vs. 3% for a general request for help with back pain(p<0.001). In multivariable models an active request was most strongly associated with a physician-assigned diagnosis of drug-seeking behavior(OR 8.10; 95% CI 2.11-31.15;p = 0.002); other major patient and physician characteristics, including gender and race, did not have strong associations with drug-seeking diagnosis. Physicians described short courses of opioid medications as a strategy for managing patients with pain while avoiding opioid overuse.
When patients make a specific request for opioid pain medication, physicians are far more likely to suspect that they are drug-seeking. Physician suspicion of drug-seeking behavior did not vary by patient characteristics, including gender and race. The strategies used to assess patients further varied widely. These findings indicate a need for the development of better clinical tools to support the evaluation and management of patients presenting with pain.
疼痛主诉很常见，但临床医生越来越担心阿片类止痛药物的过度使用。这可能导致真正疼痛的患者被污名化为“寻求药物者”，即试图获取非医疗所需药物的人。我们评估了患者对特定阿片类止痛药物的请求是否会导致医生将他们归类为寻求药物者并改变管理决策。
对192名门诊初级保健医生观看描述背痛患者的视频短片后的访谈进行混合方法分析。对于每个展示，医生被随机分配观看对特定药物的积极请求或对疼痛帮助的更一般请求。主要结果是医生将“寻求药物”作为背痛患者的潜在诊断。其他结果包括医生将采取的其他行动以及医生是否会开出所请求的药物。21%看到对羟考酮的特定请求的医生将寻求药物行为作为潜在诊断，而看到对背痛帮助的一般请求的医生中这一比例为3%（p<0.001）。在多变量模型中，积极请求与医生指定的寻求药物行为诊断最密切相关（OR 8.10；95%CI 2.11 - 31.15；p = 0.002）；其他主要患者和医生特征，包括性别和种族，与寻求药物诊断没有强烈关联。医生将阿片类药物的短期疗程描述为管理疼痛患者同时避免阿片类药物过度使用的策略。
当患者对阿片类止痛药物提出特定请求时，医生更有可能怀疑他们是寻求药物者。医生对寻求药物行为的怀疑不因患者特征（包括性别和种族）而有所不同。用于进一步评估患者的策略也差异很大。这些发现表明需要开发更好的临床工具来支持对疼痛患者的评估和管理。
