








































Physician Responses to the Opioid Epidemic in the Context of Population-Based Pain and Opioid Care


COMMONWEALTH, Volume 20, Issue 1 (2018). © 2018 The Pennsylvania Political Science Association.  
ISSN 2469-7672 (online). http://dx.doi.org/10.15367/com.v20i2-3.190. All rights reserved.

Physician Responses to the  
Opioid Epidemic in the Context of 
Population-B ased Pain and Opioid Care

AJAY D. WASAN
University of Pittsburgh Medical Center,  

University of Pittsburgh School of Medicine

The opioid epidemic is a multifaceted phenomenon in which the prescription of 
opioids for pain still plays a significant role. However, a plethora of efforts in the 
physician community following many years of epidemiological research regard-
ing patterns and characteristics of prescription opioid misuse, abuse, and addic-
tion have led to best practice guidelines agreed upon widely. Adoption of these 
guidelines and specific changes across health care systems and in individual 
provider practices have resulted in improved opioid prescribing patterns, which 
are safer and no less effective in addressing pain. The experience at the Univer-
sity of Pittsburgh and the University of Pittsburgh Medical Center is highlighted 
as an example of progressive change to address the simultaneous epidemics of 
poorly controlled chronic pain affecting 100 million adults in this country and 
prescription opioid use disorders affecting 2.2 million adults.

Background

In the history of medicine, most epidemics change their fundamental 
nature over time. For example, the HIV epidemic in the United States was 
spread in the 1980s through unsafe sexual practices, but later was perpet-

uated by the sharing of dirty needles by intravenous drug abusers. The opioid 
epidemic is no different—initially lying within the complex interweaving of 



Physician Responses to the Opioid Epidemic  123

yet- to- be-f ully- understood sociocultural issues (Quinones 2015) and subse-
quently in the overlay of two public health challenges: the better treatment of 
chronic pain (affecting 100 million US adults, an epidemic in itself) and the 
appropriate prescribing of opioids for pain relief (National Academies of Sci-
ences, Engineering, and Medicine 2017; Institute of Medicine 2011).

The opioid epidemic of the past 10 years (versus the earlier epidemic of 
heroin addiction in the 1970s) was triggered, to some considerable extent, by 
the overprescribing of prescription opioids for pain, with a subsequent shift 
to heroin use by people without pain (National Academies of Sciences, Engi-
neering, and Medicine 2017). In 2015, the number of opioid deaths from illicit 
opioids surpassed those from prescription opioids. Approximately 2 million 
people have a prescription opioid use disorder, while substantially more use 
heroin (Guy et al. 2017). And yet, the epidemics of chronic pain and opioid 
use disorder continue to be entwined, as 80% of heroin users report starting 
with prescription opioids, and 50% of heroin users in substance use disorder 
(SUD) treatment report having chronic pain (National Academies of Sciences, 
Engineering, and Medicine 2017).

Provider Responses

There has been a range of responses from physicians to combat the environ-
mental supply of unnecessary opioids, and in 2011 the rates of opioid prescrib-
ing for pain began to decrease, after increasing fourfold from 1999 to 2011 
(Frenk, Porter, and Paulozzi 2017). This article will summarize the responses 
to the opioid epidemic from those who prescribe opioids. This is referred to 
as the point of care of opioid prescribing, which is the most upstream part in 
the cascade of opioid addiction among patients with pain. The origins and 
sustaining factors of the epidemic are discussed in detail elsewhere in this 
issue of COMMONWEALTH.

The problems associated with the overprescribing of prescription opioids, 
primarily for chronic noncancer pain, have been described in the medical 
literature for over a decade through scores of reviews and research publica-
tions. There is a fundamental distinction between pain due to cancer (which 
is known to respond very well to opioids) and pain not due to cancer, such as 
chronic low back pain or pain from nerve injury (neuropathic pain).

One of the most influential reports was a review in The New England 
Journal of Medicine in 2003 by Ballantyne and Mao who described many of 
the fundamental uncertainties regarding opioid therapy for chronic noncan-
cer pain, such as the unknown degree of efficacy, the development of toler-
ance (which means less pain- relieving effects of the opioid over time), and the 



124 AjAy D. WAsAn

emerging rates of addiction (Ballantyne and Mao 2003). Concurrently, with 
FDA approval in 1996 of Purdue Pharma’s OxyContin for pain, prescriptions 
of oxycodone increased for noncancer pain, which became a widespread prac-
tice in certain parts of the country, such as Appalachia. Subsequently, reports 
of addiction to OxyContin and diversion, from states such as West Virginia, 
frequently appeared in newspapers and magazines and on television.

The medical research community took note of these issues and began 
studying patients who were prescribed opioids for noncancer pain and exam-
ining who was more likely to misuse opioids (such as self- medicating by tak-
ing extra for pain or concurrent use of illegal drugs), abuse them (such as 
mixing them with alcohol to become intoxicated), or become addicted (a 
total loss of control in taking opioids and an incessant drive to obtain more, 
regardless of the negative consequences). Misuse, abuse, and addiction lie on 
a continuum of severity and are labeled opioid use disorders. Misuse can lead 
to addiction, although the rate of progression and the incidence of progression 
still remain unknown.

Generally speaking, 40% of those who are prescribed opioids chronically 
for noncancer pain will misuse them, and 5%–15% will become addicted 
(Vowles et al. 2015). To provide some context, the rate of nonadherence to 
medications for other chronic diseases, such as diabetes or congestive heart 
failure, is also 40%. For chronic pain and opioids, the problem is taking too 
much of the medication, and for the latter diseases, the problem is not taking 
the appropriate medications in the amounts and frequency prescribed. Thus, 
one should not be surprised at the high rates of medication nonadherence in 
the treatment of chronic pain. The focus on identifying the characteristics of 
patients who misuse or become addicted to prescription opioids resulted in 
the identification of several risk factors that predicted opioid misuse: a prior 
history of abuse or addiction to controlled substances, concurrent use of ille-
gal drugs, a family history of addictive disorders, a history of illegal activity, 
and untreated depression and anxiety disorders (affective disorders) (Butler 
et al. 2004).

Three Pillars of Assessment for Opioid Adherence  
(Argoff et al. 2017)

1. Patient Self- Report

Standardized scales were developed that determined the likelihood of opioid 
misuse (such as the Current Opioid Misuse Measure). These are patient self- 
report checklists of problematic behaviors, such as taking more opioids than 



Physician Responses to the Opioid Epidemic  125

prescribed or borrowing medication from others (Butler et al. 2007). Scores 
on these measures have provided the clinician with a probability that a patient 
who has been prescribed opioids will misuse or already is misusing them.

The scales were a significant advance in tracking medication adherence, 
but still only generated an accurate prediction roughly 66% of the time. Never-
theless, patient self- reporting of medication-t aking behaviors is an important 
pillar of the physician assessment of medication adherence (i.e., is a patient 
taking the medication the way it has been prescribed, and if not, is he or she 
addicted?). The self- report scales are just one method of gathering adherence 
information from the patient, and a detailed clinical interview will achieve 
the same results.

2. Urine Drug Testing

The second pillar in assessing the likelihood that patients prescribed opioids 
will misuse them, or in monitoring adherence, is urine drug screening or 
urine drug testing (UDT). Drug toxicology technology advanced in the 1990s 
to give rise to commercially available quantitative urine drug- testing plat-
forms, first known as the gas chromatography–mass spectroscopy method 
(GCMS). GCMS allowed measurement of each type of illegal drug and pre-
scription opioid and other prescription medications in the urine with a high 
degree of accuracy, being able to quantify an amount as low as nanograms 
per milliliter for substances such as cocaine, oxycodone, morphine, and even 
gabapentin (a common nonopioid pain medication).

UDTs using GCMS technology revolutionized the field of medication 
adherence monitoring in patients with pain. In 2007, Wasan and colleagues 
reported the largest series to date using UDTs to monitor prescription opi-
oid adherence in 550 patients with chronic pain (Michna et al. 2007). They 
confirmed the results from earlier patient self- report studies and also found 
a 40% incidence of opioid misuse. This study, among others, led to the rapid 
and widespread adoption of UDTs as a standard of care in opioid adherence 
monitoring.

3. Provider Evaluation

The third pillar of the three- legged platform for assessing opioid adherence is 
the global assessment of the provider—namely, is the patient taking the medi-
cation properly? This may be information gathered from other providers of 
the patient (such as in the electronic medical record), reports from the family, 
inconsistencies observed in the patient (such as requesting early refills), lost 



126 AjAy D. WAsAn

or stolen prescriptions, and observed behaviors during the visit (such as seda-
tion, confusion, or intoxication).

Provider assessment was given a significant boost with the creation of pre-
scription drug monitoring programs (PDMPs). These are state- run databases 
of prescriptions of controlled substances entered by each pharmacy when a 
medication is dispensed. When a provider checks the PDMP they can see 
when the last prescription (if any) for an opioid was written by any provider in 
that state. Patients who are “doctor shopping” by going to multiple providers 
to obtain opioids can be readily identified. There has been a 30% reduction in 
opioids prescribed for pain in the states with robust PDMP programs (Finley 
et al. 2017).

Attempts to nationalize a PDMP program were thwarted by a lack of 
financial support from Congress. Subsequently, several states have agreed to 
share their PDMP data, so that a provider can check if prescriptions were 
filled in adjacent states. In 2016, Pennsylvania became the 49th state with a 
PDMP, leaving Missouri as the only state without a program. In July 2017, 
the Missouri governor issued an executive order establishing a state PDMP, 
but it has not yet been implemented. Many states, such as Pennsylvania and 
New York, require that providers check the PDMP prior to the prescription 
of opioids. For more information on PDMPs in Pennsylvania, see Mirigian et 
al. 2018, in this issue.

Patient self- reports, UDT results, and provider assessment are the three 
fundamental components of assessing adherence to prescription opioids in 
a comprehensive fashion. An abnormality in any of these domains indicates 
that the patient is misusing opioids, at the very least, and may possibly be 
addicted. Wasan and colleagues developed the most widely used research cri-
teria for identifying prescription opioid misuse, known as the Drug Misuse 
Index (Jamison et al. 2010). The Drug Misuse Index triangulates these three 
streams of data to make an overall determination of adherence versus misuse. 
It has been used in multiple studies and is considered the leading approach for 
opioid medication adherence monitoring (Smith et al. 2015).

The dose of opioid prescribed was also found to be an important pre-
dictor of complications from prescription opioid therapy, such as overdose, 
addiction, and death (Edlund et al. 2010). Since there are many different 
prescription opioid compounds of various strengths (e.g., oxycodone, mor-
phine, fentanyl), in comparing doses, conversion is made to each compound’s 
strength relative to morphine, the first prescription opioid. This is expressed 
as morphine equivalent dosing. Doses greater than 200 mg per day of morphine 
equivalents were found to independently predict increased rates of overdose, 
addiction, and death related to opioids. Subsequent work found that doses as 



Physician Responses to the Opioid Epidemic  127

low as 90 mg per day were just as predictive, and 90 mg became an important 
benchmark in determining what is a “high dose” of opioids.

However, these studies suffered from an important confounder, in that 
many of the patients who had complications from opioids were also copre-
scribed benzodiazepines, which are medications such as Valium, Ativan, 
or Xanax that negatively interact with opioids. These “tranquilizers” mag-
nify the side effects of opioids, such as sedation, confusion, and difficulty 
breathing. When additional studies controlled for the concurrent prescrib-
ing of benzodiazepines, the association between 90 mg per day of morphine 
equivalents and increased opioid complications disappeared. Nevertheless, 
the 90- mg- per-d ay benchmark has been retained in many state and national 
“best practices” recommendations.

Over the past 15 years, research has continued to investigate the impor-
tance of risk factors for prescription misuse, abuse, and addiction. Of the 
identified factors, a previous or current history of an addictive disorder is the 
most powerful risk factor in predicting opioid use disorders. However, affec-
tive disorders (such as major depression, generalized anxiety disorder, or the 
frequent combination of both—major depression with anxious features) are 
most prevalent in patients with chronic pain, afflicting at least 30% of the 100 
million adults in this country with chronic pain.

Among those patients seeking care for chronic pain, 40%–50% have an 
untreated or undertreated negative affective disorder (Dersh et al. 2006). This 
subgroup with psychiatric comorbidity is also prescribed opioids for chronic 
pain at much greater rates, likely due to worse levels of reported pain, disabil-
ity, and distress. Wasan and others across the country have studied the trajec-
tories of opioid therapy in the subgroup of chronic low back pain patients with 
negative affective disorders (Braden et al. 2009; Wasan et al. 2015).

In sum, they have found that the back pain patients with high levels of 
negative affective symptoms have 50% less pain relief with opioids, and a 
50% rate of opioid misuse. In this group of patients, the misuse phenomenon 
begins with urges to take more medication than prescribed between doses, a 
preoccupation with the next dose, and craving for more medication. Patients 
with high negative affect also tend to self- medicate for anxious and depres-
sive feelings or insomnia through taking extra opioids (Martel et al. 2014). 
While perhaps understandable, this is considered nonadherence to opioid 
therapy, and overtaking opioids is the most frequent presentation of opioid 
misuse.

These clinical studies and continued observations of problematic opi-
oid prescribing involving high doses to patients with risk factors for opioid 
complications led state and federal authorities as well as medical professional 



128 AjAy D. WAsAn

societies to draft best practice guidelines for opioid therapy for chronic pain. 
By and large, over a period of several years, these various guidelines are quite 
consistent, beginning with the American Pain Society–American Academy of 
Pain Medicine (APS/AAPM) guidelines in 2009, and most recently, the 2016 
primary care opioid prescribing guidelines for chronic pain released by the 
Centers for Disease Control and Prevention (CDC) (Chou et al. 2009; Dow-
ell, Haegerich, and Chou 2016). Despite having many of the same authors, 
including the same lead, one remarkable difference between the APS/AAPM 
and CDC guidelines is that the bar for acceptable evidence regarding opioid 
prescribing was changed (Busse, Juurlink, and Guyatt 2016; Tayeb et al. 2016).

In the APS/AAPM guidelines, studies of patients who were prescribed opi-
oid therapy for at least three months were considered, and this led to the con-
clusion that, for chronic pain, there is moderate evidence that opioids can be 
effective. In the CDC guidelines, only studies that tracked patients after one 
year of treatment were considered acceptable, none of which exist. This led 
the CDC report to conclude that opioids are not effective for chronic pain, and 
this conclusion has dramatically affected practice across the country, leading 
many primary care physicians to reduce or eliminate opioid prescribing for 
chronic noncancer pain.

While in the treatment of chronic disease, studies of longer than one- year 
duration would seem the most prudent to include for consideration, there are 
scarcely any studies of any pain medication (e.g., anti- inflammatory agents 
such as naproxen) that are more than a year long, and the vast majority are 
less than six months in duration (Tayeb et al. 2016). If one were to apply to 
all pain medications the same standard of yearlong follow- up for inclusion as 
acceptable studies in evidence- based guidelines, at least 75% of the existing 
medication guidelines for pain management would be dismissed. Thus, apply-
ing a standard for acceptable evidence that is far beyond what the field of pain 
management considers acceptable is far outside the norm for evidence- based 
guidelines for any treatment for pain.

This issue of standards for evidence inclusion is the most controversial 
in the CDC guidelines, but the recommendations for dose limits also were 
quite provocative (Busse, Juurlink, and Guyatt 2016). The CDC guidelines 
suggested that there is no evidence that doses greater than 90 mg of mor-
phine equivalents per day are more effective for chronic pain, and that these 
doses are associated with greater complications. As noted, this supposition 
has weak supporting evidence; nevertheless, it has sparked many insurance 
companies to deny authorization for total daily doses greater than 90 mgs, 
even in patients who have been on higher doses for long periods of time with 
evidence of improved pain and function, and no misuse.



Physician Responses to the Opioid Epidemic  129

The majority of recommendations were well received, however, being 
mainstream and consistent with other guidelines. The common elements 
among many of these guidelines are that patients should be considered for 
opioids for chronic pain only after a diagnosis has been made through a medi-
cal evaluation, including a detailed history, physical exam, and review of per-
tinent studies; merely describing a patient having pain in the right leg, for 
instance, is not a diagnosis. Opioids should only be considered after several 
nonopioid options have failed, such as anti- inflammatory agents or physical 
therapy. Indeed, it is frequently pointed out that many patients with musculo-
skeletal pain are prescribed an opioid even before physical therapy is ordered.

Opioids should be considered a trial in which the patient and provider 
mutually agree on benchmarks for success, such as improvements in pain 
and/or function, with no issues of misuse. Opioid treatment agreements are 
recommended to facilitate this communication and mutual expectations. Ide-
ally, any successful treatment for chronic pain should improve pain and func-
tion together. However, it is quite common for patients to say that a treatment 
has indeed helped them and improved their quality of life through being able 
to increase their activity, while their level of pain (most commonly rated on 
a 0–10 scale, with 10 being the most severe) has not changed. Hence, changes 
in pain and changes in function are not always linked, which is a crucial con-
sideration in evaluating the success or failure of treatments for chronic pain.

When starting opioids, it is important to start with low doses of short- 
acting opioids, which typically last 3–6 hours. This strategy avoids the com-
plications of higher doses, particularly in the elderly, and allows a window to 
evaluate their effectiveness and tolerability. If opioids are deemed effective, 
then either switching the short-a cting opioids to longer- acting formulations 
or adding long- acting opioids to short- acting opioids is frequently recom-
mended. This approach avoids the peaks and valleys in blood levels of medi-
cation and levels of pain related to the dosing of short- acting opioids only. A 
core principle of managing chronic pain is using treatments that minimize 
the possible spikes in pain levels that occur frequently during the day related 
to activity, or that occur spontaneously at night.

In terms of monitoring adherence, the guidelines are very consistent in 
recommending the three pillars of assessment: patient self- report, UDTs, and 
provider evaluation. There are no agreed- upon intervals to do each of these 
things (which will vary from patient to patient, ideally based on their risks of 
opioid misuse), but generally when starting opioids, patients are seen within 
the first 2–4 weeks. When stable doses have been achieved with documenta-
tion of good adherence, patients are often seen for reevaluation every 3–6 
months. If opioids are discontinued, it is recommended that they are tapered 



130 AjAy D. WAsAn

slowly, such as a 10%–20% reduction every month in total daily dose, except 
for the scenarios of addiction to opioids or diversion.

As an illustration of opioid guideline implementation, in 2015 the Uni-
versity of Pittsburgh Medical Center (UPMC) began operationalizing good 
opioid care practices across its integrated delivery network of 25 hospitals, 400 
outpatient clinics, and a health insurance plan with 1.8 million members. This 
was most salient in a metropolitan region noted by the CDC to be in the upper 
25% in the country of rates of opioid prescribing and overdose deaths related 
to opioids. UPMC is the largest academic integrated delivery network in the 
nation, and approximately 50% of people in the Pittsburgh metropolitan area 
of 2.2 million people receive at least some medical care through UPMC.

Thus, the opioid epidemic was also an opportunity to do effective 
population- based pain care to target this intersection of pain and opioid use. 
A multipronged approach was taken to improve opioid care by following the 
2009 APS/AAPM prescribing guidelines for chronic pain, and scaling up/
translating the clinical implications of much of the published opioid research, 
such as that of Dr. Wasan, who was leading these population- based research 
efforts at the University of Pittsburgh.

First, a system- wide advisory committee (the Pain Steering Committee) 
was formed, consisting of leaders across UPMC, including several physician 
specialties (pain medicine, physiatry, psychiatry, primary care, and emergency 
medicine), nursing executives, hospital leaders, quality improvement special-
ists, finance administrators, and executives from the health insurance plan. 
The committee quickly achieved consensus that we must target the intersec-
tion between good pain care and opioid prescribing through improving pain 
care overall, and opioid care specifically.

We also agreed to focus on process improvements, since, like many health 
care systems across the country, high- quality outcomes data are still not 
widely available or able to be tracked sufficiently when changes to care are 
made. The field of medical informatics is still evolving toward this goal to 
enable better assessment and delivery of value- based health care. We con-
ducted a needs assessment in multiple medical specialties regarding pain care. 
With the resources allotted to our committee by UPMC, we improved opioid 
care delivery in the following nine ways, as summarized in Table 1.

Below is more detail on some of these improvements.

1. Widely disseminating the Pennsylvania and 2016 CDC guidelines.
2. Mandating online continuing education in pain and opioid care for 

500 primary care and specialty physicians along with 2,000 nurse 
practitioners and physician assistants.



Physician Responses to the Opioid Epidemic  131

3. Identifying those providers who prescribed high- dose opioids 
for chronic pain to many patients using UPMC Health Plan data 
(>90 mg of morphine equivalents for >90 consecutive days), and 
then conducting an intervention in a select group of primary care 
physicians. This intervention (the 90- 90 Program) individually 
mentored physicians on individual patient cases of their own to 
improve opioid care by slowly reducing the dose, adding nonopioid 
medications and physical therapy, and more tightly doing adher-
ence monitoring. This process is known as academic detailing, with 
studies supporting its effectiveness in pain care specifically (Lieb-
schutz et al. 2017). Compared to a control group of 90- 90 physi-
cians who received the guidelines but no individual mentorship, 
prescribed opioid doses were reduced by an average of 30% over a 
one- year period in the intervention group.

4. Providing a range of clinical tools in the outpatient and inpatient 
electronic medical records to improve pain and opioid care, such 
as posting of opioid guidelines, dose conversion tables, a resource 
list facilitating referral to pain or addiction medicine specialists, 
prescribing intranasal naloxone to patients who have overdosed or 
who are prescribed opioids and are at a higher risk of overdose, and 
an individual physician “opioid dashboard” enabling each physi-
cian to track across their patient panel as a whole, and for patients, 
individual opioid care metrics (such as opioid doses, opioid use 
agreements, UDTs, and compliance checklists).

5. Promoting continuing medical education opportunities to satisfy 
maintenance of certification requirements for internists through 
a monthlong project to track opioid doses and use of opioid 

Table 1. nine Improvements to Opioid Care Delivery from UPMC

1. Disseminate Pennsylvania and 2016 CDC guidelines widely

2. Mandate online continuing education for health care professionals

3. Conduct intervention (90-90 Program) in select group of physicians

4. Provide clinical tools in electronic medical records

5. Promote continuing medical education opportunities

6. Create pathway in emergency departments for MAT/Suboxone

7. Embed social workers in clinics to comanage Suboxone prescribing with MDs

8. Collaborate and coordinate care via University of Pittsburgh Opioid Task Force

9. Expand multidisciplinary pain treatment resources in pain clinics



132 AjAy D. WAsAn

agreements in their patients with chronic pain. This was completed 
by 300 primary care physicians.

6. Creating a pathway in the emergency departments for assessing 
the need for medication- assisted therapy and enabling Suboxone 
prescribing.

7. Embedding social workers with addiction medicine training in 
primary care and pain specialty clinics, along with training physi-
cians, to prescribe Suboxone to patients with opioid use disorders, 
with or without pain.

8. Collaborating with addiction medicine clinicians, services, and 
programs, and local and regional Department of Health officials 
and law enforcement throughout the western Pennsylvania region 
via the University of Pittsburgh Opioid Task Force to better coor-
dinate opioid addiction care.

9. Expanding multidisciplinary pain treatment resources in pain 
specialty clinics, such as the addition of a psychologist and a psy-
chiatrist, and improved physical and occupational therapy services, 
with providers trained specifically in chronic pain rehabilitation.

Conclusion

Across the United States, the physician focus on improved opioid prescribing 
for chronic pain has resulted in an overall drop of 12% in the rate of opi-
oid prescribing since 2011, decreases in the average milligrams of morphine 
equivalents per prescription, as well as a 30% drop in the rates of prescribing 
high-d ose opioids, >90 mg per day (Guy et al. 2017). In western Pennsylva-
nia specifically, these metrics have dropped even more sharply compared to 
the rest of the country (such as a 14% drop in the rate of opioid prescribing), 
and as a result, our region is no longer in the upper 25% of opioid prescrib-
ing rates in the country, and is now in the middle 50% tier (Guy et al. 2017). 
Local and regional efforts through UPMC and the University of Pittsburgh 
Opioid Task Force have certainly contributed to this success, and illustrate 
how population- based pain and opioid care can be translated effectively from 
clinical studies and guidelines to widespread clinical practice.

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Ajay D. Wasan is the vice chair for pain medicine in the Department of Anesthesiology 
at the University of Pittsburgh Medical Center (UPMC) and a professor of anesthesiology 
and psychiatry in the University of Pittsburgh School of Medicine. He is board certified in 
pain medicine and completed fellowship training in pain medicine in the Anesthesiology 
Department at Brigham and Women’s Hospital and Harvard Medical School. He is also 
board certified in psychiatry and completed a residency in psychiatry at Johns Hopkins. 
He is cochair of a systemwide committee to improve pain care across UPMC.




